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THE  RADIOGRAPHY 
OF  THE  CHEST 

Vol.  I. 

PULMONARY  TUBERCULOSIS 

With  9  Line  Diagrams  and  99  Radiograms 


BY 

WALKER  OVEREND,  M.A.,M.D.(Oxon).B.Sc.(Lond.) 

Hon.  Radiologist  and  Physician  to  the  Electrotherapcntic  Department, 
East  Sussex  Hospital  (Hastings)  ;  Radiologist  to  the  City  of  London 
Hospital  for  Diseases  of  the  Chest  (during  the  War) ;  late  Chief  Assistant 
in  the  X-Ray  Department,  St.  Bartholomew's  Hospital ;  Physician  to  the 
Prince  of  Wahs^  Hospital,  London,  and  Radcliffe  Travelling  Fellow. 


ST.  LOUIS 

C    V.    MOSBY   COMPANY 

1920 


'cL-t,<J.<^—^X^-' 


d 


Pi  iiile<l  in  Grtal  Britain 


To  My  Wife 


PREFACE 

During  the  present  decade,  the  manufacture  of  more  powerful 
installations,  the  improvement  of  special  technique,  and  the  gradual 
accumulation  of  knowledge,  have  greatly  enhanced  the  value  of 
X-ray  examination  in  the  diagnosis  and  prognosis  of  diseases 
of  the  chest.  Nevertheless,  it  is  always  expedient  to  check  and 
compare  the  results  by  means  of  the  usual  methods  of  investigation  ; 
although,  on  the  other  hand,  in  many  instances  radiography  alone 
has  proved  absolutely  decisive.  The  real  foci  of  disease  may  be 
concealed  by  superimposed  shadows,  or  by  the  persistent  sequelae 
of  obsolete  lesions.  Consequently,  the  correct  inierprelation  of 
pulmonary  opacities  may  become  a  very  difficult  problem,  and 
necessitate  the  exercise  of  expert  clinical  skill  as  well  as  a  wide 
radiological  experience.  For  this  reason,  the  data  of  physical 
examination  have  been  summarised  and  included,  whenever 
possible,  throughout  the  book. 

I  have  attempted  to  describe  the  majority  of  the  types  of  pul- 
monary tuberculosis,  with  the  commoner  localities  of  incipient 
disease,  and  have  adopted,  for  this  purpose,  a  radiological  class- 
ification which  is  personal  and  provisional.  In  order  to  anticipate 
criticism,  I  may  emphasise  the  great  complexity  of  the  subject  and 
the  impossibility — in  the  absence  of  anatomical  control — of  placing 
accurately  many  intermediate  forms.  For  instance,  examples  of 
perihilar  nodal  tubercle  may  assume  a  pseudolobar  expression  ; 
cases  of  mild  diffuse  fibroid  arc  in  reality  attenuated,  often 
arrested ;  whilst  some  of  those  depicted  under  the  heading  of 
minor  phthisis  might  have  been  included,  with  almost  equal  justice, 
in  the  following  chapter  on  iibroid  affections  of  the  lung. 

The  large  number  of  radiograms — permitted  by  the  generous 
consideration  of  the  publishers — has  rendered  it  more  convenient 
to  devote  this  volume  to  the  description  of  pulmonary  tubercle 
alone;  in  the  second,  non-tuberculous  diseases  of  the  lung  and 
affections  of  the  heart  and  aorta  will  be  discussed.  With  the  ex- 
ception of  a  few  woodcuts  and  radiograms — mentioned  below — 
the  illustrations  are  original.  Some  have  been  taken  at  the  City  of 
London  Hospital  for  Diseases  of  the  Chest,  others  at  the  East 


Sussex  Hospital ;  a  few  are  selected  from  patients  sent  by  medical 
friends.  Reproduction  has  been  allowed  by  the  medical  staffs  and 
by  local  medical  confreres.  I  seize  this  opportunity  of  recording 
my  very  grateful  thanks.  Of  the  woodcuts,  2,  3,  4,  6,  9  are  after 
Rieder,  Schut,  Piery,  and  Besangon  ;  radiograms  4,  5,  65B,  and  68 
have  been  enlarged  from  Assmann. 

A  list  containing  standard  text-books  and  periodicals  of  cognate 
literature  is  given  in  the  Appendix.  Piery's  "Manual,"  I  may 
mention,  has  been  of  great  assistance,  from  the  clinical  point  of 
Tiew,  in  the  preparation  of  Chapter  VII. 

WALKER  OVEREND. 
St.  Leonards-on-Sea. 


CONTENTS 

CHAP.  PAGE 

I, — The  Normal  Chest i 

II. — Classification  :      Tuberculosis     of    Bronchial 

Glands        .        . i8 

III. — Bronchopneumonic   Nodular  and  Nodal  Types  33 

IV. — Bronchopneumonic  PsEUDOLOBAR  Tubercle  .        .  41 

V. — Minor  Phthisis 48 

VI. — Fibroid  Phthisis 58 

VII. — Pneumonic  Phthisis:  Miliary  Tubercle       .        .  68 

VIII. — The  Complications  of  Pulmonary  Tuberculosis  .  78 

IX. — The     Radiological     Diagnosis     of     Pulmonary 

Phthisis 92 


RADIOGRAPHY    OF    THE    CHEST. 


CHAPTER  I 

The  Normal  Chest. 

The  general  principles  of  X-ray  technique  are  described 
in  British  text-books  of  radiology;  nevertheless,  it  may  be 
advantageous  to  make  a  few  remarks  referring  exclusively 
to  the  examination  of  the  chest.     For  radioscopy,  as  well 
as   radiography,  soft   X-ray  tubes  with    tungsten  targets 
should  always  be  employed.     The  best  degree  of  softness 
is   between   6   and   7    Bauer ;  the  milliamperage  for  the 
radioscopy  being  about  2  to  3,  the  diaphragm  of  the  tube- 
box  being  contracted  down  for  examination  of  the  apices, 
the  hila  or  any  abnormal  opacity.     For  radiography  the 
milliamperage  should  be  from  7  upwards.     The  exposure 
is  made  in  moderatel}''  deep  inspiration,  in  a  condition  of 
complete  immobilit}',  and  should  not  last  longer  than  from 
5  to  10  seconds.     It  is  possible,  by  means  of  intensifying 
screens  and  massive  amperage,  to  reduce  this  period  to 
the  fraction  of  a  second ;  but  such  pictures  may  not  be 
entirely  free  from  grain,  and  the  finer  details  then  become 
invisible.     The  distance  of  the  fluoroscopic  screen  from 
the   target   should    be  from   20  to    24  inches,  and  for   a 
complete  photograph  plates  of  15  in.  by  12  in.,  or  12  in.  by 
lo  in.  are  necessary.     For  the  oblique  diameters  and  the 
apices  plates  of  10 in.  by  Sin.  may  be  sufficiently  large. 
Stereoscopic  pictures  of  the  varied  diameters  maybe  made 
in  the  usual  manner ;  it  is  preferable,  however,  to  remove 
the  target  two  inches  towards  the  diaphragm   and  cardiac 
apex  for  the  second  radiogram,  and  to  view   the  plates 


2  Radiography  of  the  Chest 

laterally  on  the  stereoscope.  In  this  way  the  whole  chest, 
is  more  easily  obtained  on  the  radiogram. 

When  a  complete  radiological  investigation  of  the  chest 
is  made,  several  principal  or  cardinal  positions  are  selected 
but  the  one  most  generally  useful  is  the  anterior  or  dorso- 
ventral;  the  rays  entering  the  chest  from  the  back,  with 
the  anode  at  the  level  of  the  junction  of  the  fourth  costal 
cartilage  with  the  sternum,  and  the  fluorescent  screen 
placed  over  the  front  of  the  chest.  With  feeble  invalids 
the  recumbent  posture  is  preferable,  although  the  upright 
or  sitting  position  possesses  several  advantages  and 
sometimes  is  indispensable.  The  image  on  the  screen 
presents  three  distinct  areas,  one  median  and  two  lateral. 
The  median  zone  is  dark,  and  increases  in  breadth  towards 
the  left  side  of  the  patient  from  above  downwards.  It  is 
termed  the  median  shadow,  and  is  produced  by  the  summa- 
tion of  opacities  due  to  the  greater  densities  of  the  vertebral 
column,  heart,  great  vessels,  and  the  sternum.  The  lateral 
areas  are  the  7'ight  and  left  pulmonary  fields.  These  are 
bounded  on  each  side  by  the  ribs  and  below  by  the 
diaphragm.  The  fields  are  roughly  triangular  in  shape, 
and  are  crossed  by  the  shadows  produced  by  the  ribs,  which 
run  obliquely  from  above  downwards,  so  that  the  anterior 
portions  of  the  higher  ribs  intersect  the  posterior  opacities 
of  the  lower.  Since  the  cartilages  of  the  ribs  are  trans- 
parent to  the  rays,  there  is  a  gap  between  the  anterior 
osseous  extremity  of  each  rib  and  the  sternum.  As  age 
advances  calcification  of  the  first  rib  cartilages  is  common; 
also  the  same  process  is  often  seen  in  the  form  of  linear 
opacities  running  along  the  upper  and  lower  borders  of  the 
cartilages  of  the  lower  ribs.  Each  pulmonary  field  is 
divided  into  two  unequal  parts  by  the  horizontal  opacity 
due  to  the  clavicle.  The  lower  border  or  diaphragm 
consists  of  two  arches  (with  the  convexities  directed  up- 
wards) which  rise  and  fall  with  the  movements  of 
respiration. 

The  outlines  of  the  heart  are  visible  outside  the  shadow 


Radiography  of  the  Chest  3 

of  the  vertebral  column,  commencing  about  one  inch  below 
the  sternal  ends  of  the  clavicles.  On  the  right  the  margin 
is  practically  straight ;  the  upper  two-thirds  correspond  to 
the  ascending  aorta  and  the  superior  vena  cava  ;  the  lower 
third  to  the  right  auricle.  On  the  left  three  rounded 
projections  may  be  more  or  less  in  evidence.  The  upper 
corresponds  to  the  bend  of  the  aortic  arch  as  it  passes 
backwards  to  become  the  descending  arch  and  descending 
aorta.  It  has  been  termed  the  left  aortic  bulge.  As  age 
advances  it  becomes  more  pronounced  and  tends  to  reach 
the  level  of  the  sterno-clavicular  joint.  The  middle 
eminence  denotes  the  position  of  the  pulmonary  artery, 
and  the  lowest  and  largest  is  formed  by  the  left  ventricle. 
In  certain  diseases,  as  in  mitral  stenosis,  h3'pertrophy  of 
the  left  auricle  is  seen  to  produce  an  intermediate  convexity 
between  the  pulmonary  artery  and  the  left  ventricle. 

Closely  connected  with  the  median  shadow  is  that  of  each 
hilum  or  root  of  the  lung,  of  which  the  right  is  the  more 
conspicuous,  the  lower  part  of  the  left  being  concealed  by 
the  cardiac  opacity.  Between  the  right  hilum  and  the 
heart  a  clear  space  is  occasionally  seen,  which  corresponds 
in  position  with  the  branch  of  the  right  main  bronchus 
running  towards  the  diaphragm.  Each  hilum  with  its 
upward  and  downward  prolongations  presents  the  form  of 
a  crescent.  By  slight  rotation  of  the  patient  to  the  right, 
or  by  elevation  of  the  screen  a  foot  from  the  chest,  a  better 
radioscopic  picture  of  the  right  hilum  is  obtained.  In  good 
radiograms  the  branches  proceeding  from  the  hilum  may 
be  followed  upwards,  outwards  and  downwards,  and  it  is 
seen  that  they  subdivide  and  finally  produce  a  retiform 
appearance  towards  the  periphery,  which  has  been  termed 
the  radio-structure  of  the  lung. 

The  shadow  of  the  right  dome  of  the  diaphragm  lies 
higher  than  that  of  the  left.  In  ordinary  quiet  respiration 
the  curve  of  the  convexity  remains  the  same  both  in  descent 
and  ascent.  At  the  inner  e.xtremity  between  each  cupola 
and    the    heart    lies    the  cardio-phrenic  sulcus.       In    deep 


Radiography  of  the  Chest 


Diagram  i. 


Chest. — Anterior  or  dorso-ventral  view.  For  the  sake  of  clearness  the 
lower  ribs  on  the  right  side  are  omitted. 

Heart.— R.A.,  right  auricle;  R.V.,  right  ventricle;  L.V.,  left  ventricle; 
Aur.A.,  position  of  auricular  appendix;  Pul.C,  pulmonary  artery;  A.B., 
left  aortic  bulge;  S.V.C.  and  A. A.,  superior  vena  cava  and  ascending 
aorta. 

R.A.,  L.A.,  right  and  left  pulmonary  apices;  R.C1.,  L.Cl.,  right  and  left 
clavicles;  Cor.,  coracoid  process  of  scapula;  Ac,  acromion;  L.H., 
humerus;  L.N.,  left  nipple;  L.H.,  R.H.,  right  and  left  hila;  P.V.,  para- 
vertebral; MC,  mid-clavicular;  Ax.,  axillary  bronchi  of  upper  lobe; 
M.L.B.,  chief  bronchus  of  right  middle  lobe;  L.L.B.,  bronchi  running  to 
lower  lobes;  V.C,  vertebral  column,  the  figures  refer  to  the  number  of 
rib,  vertebral  and  sternal  portion;  R.D.M.,  L.D.M.,  right  and  left  phrenic 
leaflets;  R.Car.P.S.,  right  cardio-phrenic  sulcus;  R.Cos.Ps.,  right  costo- 
phrenic  sulcus ;  V.  vertebral  border  of  scapula. 


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Radiography  of  the  Chest  5 

inspiration,  when  the  diaphragm  descends,  the  sulcus 
widens,  and  occasionally  completely  separates  the  shadows 
of  the  heart  and  the  central  tendon.  At  times  a  fine 
shadow  is  visible  within  the  sulcus  on  either  side  of  the 
heart,  which  is  the  expression  of  the  pericardial  sac.  At 
the  outer  extremity  of  the  diaphragm,  between  it  and  the 
ribs,  lies  the  costo-phreiiic  sulcus,  obliteration  of  which  is 
produced  by  adhesions  and  thickenings  of  the  pleura,  or 
by  the  presence  of  small  pleural  effusions.  To  see  the 
latter  the  upright  position  is  necessar}-.     (Diagram  i.) 

The  posterior  or  ventro-dorsal  position  is  obtained  by 
arranging  the  tube  in  front  and  the  screen  on  the  back. 
It  is  the  reverse  picture,  the  apex  of  the  heart  now  lying 
to  the  left  side  of  the  observer.  The  shadows  of  the 
posterior  divisions  of  the  ribs  stand  out  more  prominently, 
but  they  appear  thinner  and  the  interspaces  narrower  than 
in  the  anterior  position  because  they  are  nearer  the  screen. 
The  lower  border  of  the  rib  presents  an  overhanging 
margin,  3  to  4  inches  long,  best  seen  in  the  7th  to  the  9th, 
which  corresponds  to  the  costal  groove,  sulcus  costalis, 
and  lodges  the  intercostal  vessels  and  nerve.  On  the 
other  hand,  the  cardiac  outlines  are  less  sharp  and  the 
opacity  is  larger.  The  vertebral  border  of  the  scapula  is 
more  obvious  (Radiogram  i),  and  can  easily  be  identified 
by  movement  of  the  upper  arm.  The  excursions  of  the 
diaphragm  and  changes  of  the  costophrenic  sulci  are  easier 
to  follow.  When  a  radiogram  is  taken  it  is  preferable  to 
fix  the  target  at  the  level  of  the  fifth  dorsal  spine. 
Although  this  view  is  not  so  generally  used  as  the  former, 
it  cannot  be  omitted,  since  many  lesions,  especially  those 
of  tuberculosis,  often  lie  nearer  the  posterior  surface  and 
are  therefore  more  accessible  to  the  screen  and  plate  in 
this  position. 

The  right  antero-latcral  or  oblique  posture  is  obtained  when 
a  patient  in  the  anterior  or  dorso-ventral  position  is  slowly 
rotated  from  the  left  to  the  right  of  the  observer,  until  the 
right  mammary  line   comes  into  contact  with  the  screen. 


6  Radiography  of  the  Chest 

The  rays  then  penetrate  the  chest,  from  behind  forward, 
obHquely  at  an  angle  of  about  45^^.  If  recumbent,  the  left 
hand  may  be  placed  under  the  head  and  the  right  arm 
drawn  away  from  the  side  and  supported  by  an  air  cushion. 
A  sand-bag  applied  below  to  the  back  will  steady  the  chest. 
In  practice  it  is  unnecessary  to  employ  this  angle  exactly; 
it  is  sufficient  to  move  the  patient  gradually  with  the  help 
of  the  screen  out  of  the  anterior  position,  until  the  median 
shadow,  consisting  of  sternum,  heart  and  vessels,  is  thrown 
forward  from  the  vertebral  column,  and  the  best  picture 
obtained.  Three  clear  zones  (Radiogram  2)  are  distin- 
guishable ;  the  right  is  the  left  pulmonary  field;  the  middle 
small  mediastinal  area  is  limited  by  the  heart  and  aorta  in 
front,  the  vertebral  column  behind,  and  is  partially  covered 
by  both  pulmonary  fields ;  the  third  bright  area  on  the  left 
is  the  right  pulmonary  field.  The  heart  itself  appears 
triangular  ;  at  the  apex  lies  the  arch  of  the  aorta,  the  base 
is  formed  by  the  right  ventricle  and  diaphragm.  The 
vertebral  border  of  the  heart  is  constituted  below  by  the 
right  auricle,  above  which  a  less  definite  middle  portion 
consists  of  left  auricle,  although  the  pulmonary  vessels  and 
superior  vena  cava  participate.  Above  this  lies  the  ascend- 
ing aorta.  If  the  descending  aorta  is  sclerosed,  as  is  often 
the  case  in  hypertrophic  emphysema,  the  continuation  of 
the  arch  may  be  followed  over  the  vertebral  column.  In 
deep  inspiration  the  posterior  mediastinal  zone  brightens, 
the  diaphragm  descends,  and  the  inferior  vena  cava  may  be 
seen  in  the  cardio-phrenic  sulcus.  The  left  side  of  the 
cardiac  triangle  consists  of  ascending  aorta,  the  conus 
arteriosus  of  the  pulmonary  artery,  and  the  left  ventricle.. 
Sometimes  the  left  auricular  appendix  is  visible.  Between 
the  aorta  and  vertebral  column  is  the  retrocardiac  space, 
which  is  occupied  by  the  trachea  and  oesophagus.  The 
former  cuts  the  shadow  of  the  arch  and  produces  a  sharp 
contrast.  The  left  bronchus  and  one  or  more  of  its 
divisions  may  be  followed  through  the  shadow  of  the 
ventricle ;  the  right  bronchus  towards  the  spine,  and  the 


Rad.  3'- Lett  anterolateral   racJiugram.     A. A.,  aortic  arch;    L.B., 
left  bronchus;  P.A.,  pulmonary  artery;   Tr.,  trachea. 


Radiography  of  the  Chest  7 

bifurcation  space  is  defined.  Occasionally  the  left  carotid 
in  front,  and  the  innominate  artery  behind  may  be  recog- 
nised. The  right  oblique  diameter  is  useful  for  the 
determination  of  dilatation  of  the  aorta,  aneurism  of  the 
arch  and  descending  aorta,  and  for  the  recognition  of 
dilatation  of  the  left  auricle.  Also  it  is  necessary  for  the 
diagnosis  of  enlarged  bifurcation  glands,  for  mediastinal 
growths,  and  for  the  determination  of  lesions  of  the 
cEsophagus  by  the  aid  of  bismuth  paste.  Above  the 
clavicle,  in  front  of  the  dorsal  vertebrae,  opacities  due  to 
the  presence  of  endothoracic  goitre  may  be  visible. 

In  the  left  antero-lateral  or  oblique  attitude  the  patient  is 
rotated  in  the  opposite  direction,  that  is  from  right  to  left, 
(observer).  The  same  three  bright  zones  are  obtained, 
due  to  the  right  lung  on  the  left  and  a  median  mediastinal 
division.  The  heart  is  more  rounded  in  outline ;  its 
vertebral  border  is  made  up  of  left  ventricle  and  left  auricle, 
and  on  the  sternal  side  the  right  auricle  (Radiogram  3). 
In  the  sclerosed  aorta  the  arch  curves  like  a  broad  hoop 
over  the  dark  cardiac  opacity  and  the  aorta  descendens 
disappears  within  the  shadow  of  the  spine.  Small  pulsat- 
ing opacities  above  the  arch,  which  occasionally  materialize 
on  the  plate,  are  the  innominate,  left  carotid,  and  left 
subclavian.  A  pulsating  ductus  Botalli  should  be  visible 
in  this  diameter  below  the  arch  and  between  it  and  the 
pulmonary  artery. 

The  left  posterior  oblique  (postero-lateral)  diameter  is 
obtained  from  the  posterior  or  ventro-dorsal  position  by 
rotating  the  patient  until  the  left  shoulder  blade  comes 
into  contact  with  the  screen.  The  diameter  is  selected 
which  gives  the  greatest  breadth  of  the  posterior  mediastinal 
space.  This  position  is  also  employed  for  the  determination 
of  the  calibre  and  integrity  of  the  oesophagus  by  means  of 
bismuth  and  for  the  diagnosis  of  aneurism  of  the  descending 
aorta. 

The  left  lateral  examination  is  made  by  placing  the  screen 
on  the  left  lateral  aspect  of  the  patient.     The  best  results. 


8  Radiography  of  the  Chest 

are  obtained  in  thin  individuals  and  in  deep  inspiration 
The  heart  lies  close  to  the  screen,  leaving  a  clear  retrosternal 
space  above,  and  a  retrocardiac  space  below.  The  cardiac 
apex  appears  close  to  the  thoracic  wall.  The  descending 
aorta  in  thin  elderly  individuals  may  be  visible,  particularly 
if  dilated  or  aneurismal.  Small  effusions  of  the  pleura  are 
visible  in  the  retrocardiac  space.  The  retro  sternal  space 
also  widens  during  inspiration,  the  upper  portion  of  the 
heart  moving  slightly  backwards,  while  the  viscus,  as  a 
whole,  is  drawn  downwards  by  the  crura  of  the  diaphragm. 
In  this  position  the  antero-posterior  diameter  of  the  heart 
may  be  measured  by  orthodiagraph3^ 

In  the  anterior  and  posterior  positions  a  general  idea  is 
obtained  as  to  theincreaseof  illumination  during  inspiration, 
of  the  movements  of  the  ribs  and  diaphragm,  and  the 
existence  of  local  abnormal  opacities,  which  may  or  may 
not  become  less  opaque  during  the  same  phase  of  respira- 
tion. Special  attention  must  be  directed  towards  certain 
areas,  as  the  apex,  the  hilum,  the  fissures,  the  diaphragm 
and  its  sulci.  The  apex  of  the  lung  is  bounded  above  and 
laterally  by  the  first  and  second  ribs,  internally  by  the 
vertebral  column,  and  below  by  the  clavicle.  Since  the 
latter,  however,  is  not  a  fixed  line,  but  moves  with  the 
shoulders  and  during  inspiration,  it  is  preferable  to  select 
as  the  lower  boundary  a  line  drawn  horizontally  at  the 
level  of  the  junction  of  the  fourth  rib  with  the  spine.  In 
anterior  pictures  the  shadow  of  the  apex  is  partially  con- 
cealed by  the  opacities  of  the  first  rib  and  clavicle.  Well 
developed  muscles  of  the  neck,  as  the  sternomastoid  and 
sternothyroid,  impair  the  illumination  of  the  inner  half. 
The  presence  of  indurated  supra-clavicular  glands  and  of 
an  endo-thoracic  goitre  may  also  produce  a  cloudy  appear- 
ance. It  is  well,  therefore,  to  palpate  carefully  the  supra- 
clavicular triangle  in  every  case  before  screening  the  area. 
The  apices  are  less  clear  than  the  rest  of  the  lung,  and 
they  exhibit  only  a  very  slight  difference  in  inspiration  and 
expiration,  since  they  are  aerated  only  by  the  descent  of 


Radiography  of  the  Chest  9 

the  diaphragm  and  the  pull  of  the  crura  upon  the  hilum  of 
the  lung ;  when  the  patient  coughs,  both  apices  should 
expand  and  appear  brighter.  Some  apices  appear  large  ; 
in  these,  as  a  rule,  the  ribs  run  steeply  and  possess  larger 
interspaces.  The  size  is  also  dependent  on  the  position  of 
the  X-ray  tube.  They  are  smaller  when  the  tube  is  exactly 
beneath  ;  larger  when  the  target  is  at  the  level  of  the  tendon 
of  the  diaphragm,  or  a  few  inches  above  the  apex  in   the 

Diagram  2. 


Radiological  Triangles.— S.T.,  Subclavicular;  M.T,,  Middle  Triangles  or  the 
Wings ;   B.T.,  Basal  Triangles. 

cervical  region.  In  both  posterior  and  anterior  radiograms 
the  first  interspace  is  often  invisible.  If  the  upper  border 
of  the  lung  on  the  radiogram  falls  within  the  shadow  of 
the  rib  it  is  not  seen.  Often  it  is  visible,  however,  as  a 
faint  narrow  opacity  running  along  the  lower  edge  of  the 
second  rib.  According  to  some  radiologists,  when  the 
first  interspace  is  visible  the  clear  area  is  not  due  to  lung, 
but  to  the  effect  of  contrast  between  soft  muscular  tissues 


lo  Radiography  of  the  Chest 

and  the  shadows  of  the  first  and  second  ribs.  That  this  is 
not  the  case  may  be  deduced  from  the  following  observa- 
tions :  in  posterior  radiograms,  especially  in  women,  with 
some  amount  of  emphysema  of  the  upper  lobe,  plates  may 
be  obtained  in  which  the  shadow  above  described  runs 
along  the  lower  border  of  the  first  rib,  and  others  in  which 
the  shadows  produced  by  the  reticulum  of  the  lung  may  be 
followed  into  the  first  interspace,  to  become  connected  with 
small  round  areas  which  are  obviously  peribronchial  apical 
foci.  In  children  it  is  usual  to  see  a  fair-sized  first  space 
in  posterior  radiograms  taken  during  deep  inspiration. 

The  fissures  of  the  lung.  (Diagram  3.)  The  great  fissure 
begins  at  the  upper  part  of  the  hilum,  ascends  shghtly  on 
the  vertebral  surface  of  the  lung,  and  reaches  the  posterior 
border  about  three  inches  below  the  highest  point  of  the 
lung  at  the  upper  margin  of  the  vertebral  end  of  the  fourth 
rib.  It  runs  spirally  downwards  and  outwards,  crosses 
the  fifth  rib  in  the  axillary  line,  then  forwards  to  the  base 
of  the  lung,  reaching  it  a  short  distance  behind  its  anterior 
end,  where  it  turns  up  and  ends  in  the  hilum.  The 
secondary  or  horizontal  fissure,  only  present  in  the  right 
lung,  leaves  the  great  fissure  at  the  fourth  rib  in  the 
axillary  line  and  runs  horizontally  along  it  towards  the 
sternum,  where  it  turns  back  along  the  mediastinahsurface 
of  the  lung  to  the  hilum.  It  lies  above  the  nipple,  but  it 
may  be  absent,  abnormal  in  position,  or  so  adherent  as  to 
be  separated  with  difficulty.  A  shadow  seen  at^the  level 
of  these  fissures  may  indicate  interlobar  thickenings  of 
the  pleura  or  an  interlobar  empyema. 

The  hilum  lies  opposite  the  vertebral  ends  of  the  5th, 
6th  and  7th  ribs,  and  is  about  i  >^  inches  broad.  In  the 
anterior  radiograms,  its  external  border  lies  well  within 
the  space  left  between  the  osseous  extremities  of  the  2nd 
and  4th  ribs  and  the  mediastinal  shadow.  The  opacity 
is  a  summation  of  shadows  due  to  the  pulmonary  vessels 
and  lymphatics,  with  the  bronchi  and  a  certain  amount  of 
connective  tissue.      It  increases  in  extent  and  intensity  of 


Radiography  of  the  Chest 


ir 


opacity  with  age ;  it  is  more  conspicuous  in  town  dwellers, 
and  those  who  work  in  a  dust-laden  atmosphere  (pneumo- 
coniosis). 

Divisions  of  the  lung.  In  order  to  facilitate  the  description 
of  the  pulmonary  field,  it  has  been  divided  into  areas  by 
selecting  certain  more  or  less  fixed  points  and  connecting 
these  by  straight  lines.  By  drawing  a  paravertebral  line 
(where  the  heads  of  the  ribs  join  the  vertebrae)  from  the 
4th  to  the  8th,  and  another  from  the  8th  to  join  the  hori- 
zontal line  at  the  level  of  the  head  of  the  4th  in  the  axilla, 
we  obtain  a  sitbapical  or  subclavicular  triangle  within  which 

Diagram  3  (after  Piery). 


Showing  the  position  of  the  interlobar  fissures,  and  the  limits  of  the  pleura 
in  the  right  lateral  and  left  lateral  positions;   R.L.,  right  lung;   L.L.,  loft, 

lung;   N.,  nipple. 

lies  the  seat  of  election  for  adult  pulmonary  tubercle;  the 
great  fissure  traverses  the  outer  and  upper  part.  It  also 
contains  the  first  and  most  of  the  second  anterior  inter- 
costal spaces.  Another  line  is  drawn  from  the  head  of  the 
8th  rib  along  its  shaft  to  the  outer  margin  of  the  chest, 
producing  a  middle  triangle  or  wing,  within  which  are  ta 
be  sought  the  foci  of  broncho-pneumonia  in  children, 
changes  due  to  gangrene  of  the  lung,  and  the  first  signs 
of  miliary  and  perihilar  tuberculosis.  The  basal  part  of 
the  lung,  thus  separated,  is  the  diaphragmatic  area  in 
which  small  pleural  effusions  and  basal  emphysemata  are 


12  Radiography  of  the  Chest 

found  and  almost  all  adult  bronchiectases.  It  corresponds 
with  the  distribution  of  the  lower  bronchus  (Diagram  3). 

Injections  of  the  arteries  or  of  the  bronchi  may  be  made 
separately  with  substances  opaque  to  the  rays  ;  the  rami- 
fications of  each  system  will  then  appear  as  opaque 
dendriform  shadows  on  the  fluoroscopic  screen,  and  may 
be  radiographed.  The  trachea  and  the  bronchial  tree  may 
be  injected  in  situ,  or  after  removal  with  the  lungs  from 
the  cadaver.  In  order  to  control  the  flow  it  is  necessary 
that  the  injection  should  be  semi-fluid  ;  since,  as  a  rule, 
only  the  larger  branches  of  the  chief  bronchi  are  required. 
For  this  purpose  the  author  finds  an  emulsion  consisting 
of  equal  parts  barium  sulphate  and  vaselin  the  best. 
Stereoscopic  pictures  are  then  combined  and  the  distribu- 
tion of  each  branch  is  readily  recognisable.  (Vide  infra, 
page   14.) 

The  pulmonary  reticulum.  On  good  radiograms,  taken 
with  short  exposures,  a  network  of  threads  is  visible  in  the 
peripheral  and  lateral  parts  of  the  lung,  which  must  either 
be  due  to.  structures  containing  a  less  amount  of  air,  and 
therefore  interposing  some  resistance  to  the  penetration 
of  the  X  ra3^s,  such  as  blood  and  lymph,  or  the  connective 
tissue  walls  of  the  terminal  and  minute  divisions  of  the 
bronchi  themselves.  Passing  centripetally,  these  linear 
shadows  become  thicker  and  more  obvious,  and  approach- 
ing the  hilum  they  become  heavier  trunks,  assuming  the 
form  of  bronchial  and  vascular  ramifications.  The  actual 
anatomical  substratum  to  which  the  above  tracery  is 
attributable  is  still  a  matter  of  doubt  and  discussion.  Is 
it  due  to  the  arborisations  of  the  bronchi,  or  of  the  blood 
vessels,  or  both  ?  Attempts  have  been  made  to  solve  the 
question  by  the  injection  into  the  bronchi  or  blood  vessels 
of  substances,  like  emulsions  of  bismuth  carbonate,  which 
absorb  the  rays,  and  by  the  subsequent  comparison  of  the 
pictures  obtained  with  those  of  the  normal.  From  these 
•experiments  the  only  conclusion  to  be  drawn,  with  regard 
to  the  course  and  pattern  of  the  picture,  is  that  either 


Radiography  of  the  Chest  15 

might  have  been  responsible.  In  pulmonary  radiograms, 
of  the  cadaver  the  lung  tracery  is  much  less  pronounced 
than  in  the  living  subject,  and  must  be  attributed  to  the 
deficient  distension  of  the  vessels,  as  well  as  to  the  absolute 
stagnation  of  the  fluid  which  may  still  remain  within  the 
veins  and  l3''mphatics.  In  opposite  conditions  during  life, 
such  as  in  the  passively''  congested  lung  of  mitral  stenosis, 
the  arborisation  is  more  obvious  than  usual.  When  we 
consider  the  difference  of  structure  between  the  two 
systems  of  ramification,  the  vessels,  being  airless,  should 
show  a  compact  solid  shadow,  whereas  the  bronchi,  being 
tubes  filled  with  air,  should  appear,  if  cut  longtitudinally, 
as  clear  streaks  with  a  double  contour.  In  the  diffuse 
bronchiectasia  of  children,  after  pertussis,  we  meet  with 
such  pictures  in  all  parts  of  the  lung,  especially  tow^ards 
the  base  and  costophrenic  sulcus ;  moreover,  optical 
transverse  sections  are  visible  as  minute  circles  with  clear 
centres.  This  obscurit}'  of  the  rim  or  circumference  of 
the  tube  is  emphasised  when  the  walls  are  thickened  by 
connective  tissue  proliferation,  such  as  occurs  in  chronic 
bronchitis  with  emphysema,  in  the  earlier  stages  of  pul- 
monary tuberculosis,  and  in  quiet  extensive  peribronchial 
phthisis.  The  nearer  the  periphery  is  approached,  the 
more  pronounced  do  the  interweavings  and  intercrossings 
of  the  two  systems  become,  so  that  finally  a  confused 
entanglement  is  produced  which  it  is  impossible  to  inter- 
pret. Most  radiologists  are  now  of  opinion  that  both 
sets  of  arborisation  play  a  part  in  the  production  of  the 
network,  but  that  the  influence  of  the  bronchi  is  more 
pronounced  in  the  central  parts  of  the  lung;  that  of  the 
blood  vessels  is  more  apparent  at  the  periphery.  In  good 
soft  radiograms  of  the  lung,  taken  some  days  after  a  copious 
haemoptysis,  occasionally  the  seat  of  the  haemorrhage  may 
be  determined  by  the  presence  of  an  excessive  number  of 
fine  shadows,  without  central  lumina,  connected  with  a 
caseous  focus  and  situated  often  in  the  upper  posterior 
areas  of  the  lung.      The  lines  are  not  so  finely  cut  as  in  the 


14  Radiography  of  the  Chest 

bronchi,  since  the  column  of  blood  is  never  still.  The 
solution  of  the  problem,  to  some  extent,  possibly  lies  in 
•the  quality  of  the  tube.  Soft  rays  will  portray  the  vessels 
better,  slightly  harder  the  bronchi,  whereas  still  harder  rays 
will  delineate  more  exclusively  the  ribs  and  the  spine. 

The  right  bronchus  gives  off  an  apical  or  eparterial 
branch,  which  divides  into  {a)  anterior,  {b)  posterior, 
and  {c)  ascending  branches  to  supply  the  upper  lobe.  On 
radiograms  of  emphysema  with  thickened  bronchi,  we  can 
easily  make  out  three  chief  sets  of  branches ;  paravertebral 
to  the  apex,  mid-clavicular,  and  axillary,  the  mid-clavicular 
being  supplied  by  posterior  branches  of  {a)  and  {h),  the 
axillary  by  anterior  branches  of  the  same.  The  main 
bronchus  then  gives  off  a  ventral  branch  to  the  middle 
lobe  (which  is  often  visible  just  beneath  the  anterior  end 
of  the  4th  rib),  a  dorsal  to  the  apex  of  the  lower  lobe,  then 
ventral  (one  of  which  goes  to  the  azygos  lobe)  and  dorsal 
branches  to  the  rest  of  the  lower  lobe.     (Rad.  3a.) 

The  diaphragm  arises  from  the  margin  of  the  lower 
thoracic  aperture  in  two  main  divisions,  {a)  ihe  sterno- 
costal, from  the  inner  surfaces  of  the  costal  cartilages  of  the 
lower  six  ribs  and  the  back  of  the  ensiform  process,  the 
fibres  passing  backwards  as  they  ascend,  and  {b)  the  crural, 
from  the  front  of  the  bodies  of  the  upper  two  or  three 
lumbar  vertebrae  and  the  arcuate  ligaments,  to  the  posterior 
part  of  the  central  tendon.  The  right  and  left  domes  are 
supported  and  their  curvatures  preserved  by  the  elastic 
traction  of  the  lungs;  the  central  tendon  by  means  of  its 
connection  with  the  pericardium,  the  latter  being  con- 
tinuous above  with  the  deep  cervical  fascia  and  also 
attached  by  ligaments  to  the  back  of  the  sternum.  To 
measure  the  height  of  the  diaphragm.  Professor  Keith 
suggested  a  horizontal  line  drawn  at  the  level  of  the 
junction  of  the  body  of  the  sternum  with  the  ensiform 
cartilage  (meso-metasternal  line,  Dally).  In  the  normal 
thorax  this  line  crosses  the  5th  cartilage,  in  emphysema  it 
crosses  below  this  cartilage ;  if  the  ribs  are  depressed,  as 


AX.  BR. 


R.XD  3^  (Ant.)  -  Main  bronchus  of  left  upper  lobe  nijectcd  with  an 
emulsion  consisting  of  carbonate  of  lead  and  vasehn;  P.\  .. 
paravertebral  ascending  branches;  M.C..  ra.d-clav.cular 
branches;  Ax.  Br.,  branches  to  axillary  area  and  lateral  wall. 


Facing  p.  U- 


Radiography  of  the  Chest  15 

an  the  habitus  phthisicus,  it  crosses  above  the  cartilage 
{Journal  of  Anatomy  and  Physiology,  Vol.  XLII).  But  since 
the  meso-metasternal  junction  is  not  a  fixed  point,  it  is 
preferable  to  select  the  line  drawn  horizontally  at  the  level 
of  the  junction  of  the  loth  rib  with  the  spine  (Dickey). 

In  expiration  the  lateral  muscular  zone  of  the  diaphragm 
lies  in  contact  with  the  thoracic  wall.  During  inspiration 
the  enlargement  of  the  lungs  below  is  assisted  by  abduc- 
tion of  the  floating  ribs  produced  by  the  contraction  of  the 
quadratus  lumborum  and  deep  costal  muscles.  The  viscera 
and  intra-abdominal  pressure  play  an  important  part  in  the 
determination  of  the  movement  of  the  diaphragm,  by 
preserving  the  abduction  of  the  lower  ribs  and  furnishing 
a  fixed  point  for  its  sterno-costal  fibres.  When  there  is  a 
large  gastric  air  sac,  one  may  sometimes  see,  on  the  radio- 
.§ram,  the  left  crus  passing  to  the  tendon. 

The  intra-abdomihal  pressure  assists  the  elastic  traction 
of  the  lung  in  the  recumbent,  but  is  opposed  to  it  in  the 
upright  position,  the  weight  of  the  abdominal  viscera  also 
exercising  a  tug  upon  the  diaphragm.  The  condition  of 
the  abdominal  muscles  is  also  important,  that  is,  whether 
they  are  strong  and  capable  of  assuming  a  firm  reflex  tone 
in  the  erect  posture.  As  determined  by  orthodiagraphy, 
in  front,  on  standing  the  highest  point  of  the  dome  lies  at 
the  upper  edge  of  the  5th  right  and  lower  edge  of  the  5th 
left  rib.  In  dorsal  decubitus  the  dome  may  reach  the  lower 
edge  of  the  sth  rib.  Behind,  on  standing,  the  lower  edge 
of  the  9th  right  and  loth  left;  in  the  recumbent  position, 
the  lower  edge  of  the  Sth  right  and  9th  left  rib.  In  children 
the  figures  are  somewhat  lower;  sometimes  during  deep 
inspiration  almost  the  whole  extent  of  the  pleural  sinus  is 
•occupied  by  lung. 

In  the  horizontal  position  the  diaphragm  ascends  nearly 
one  inch,  since  the  elastic  traction  of  the  lung  is  now 
assisted  by  the  abdominal  viscera.  In  right  lateral 
decubitus,  the  right  dome  rises  higher  than  in  dorsal 
decubitus,  and  the  heart  sinks  a  little  to  the  right.     In  left 


1 6  Radiography  of  the  Chest 

lateral  decubitus  the  left  dome  is  less  elevated  than  the 
right  in  right  lateral  decubitus,  but  in  this  position  the  liver 
produces  considerable  stretching  and  lowering  of  the  right 
dome,  so  that  the  complimentary  space  or  pleural  sinus  is 
almost  entirely  exposed  on  that  side.  In  the  lateral 
decubitus,  therefore,  the  inspiratory  depression  practically 
only  affects  the  dome  of  the  side  nearer  the  couch.  The 
free  side  shows  little  or  no  movement,  since  its  compli- 
mentary sinus  is  already  laid  bare,  and  the  dome  can 
scarcely  descend  any  farther. 

In  quiet  respiration  both  domes  descend  about  half  an 
inch.  During  the  descent  the  costophrenic  sinus  and  the 
convexity  of  the  dome  do  not  change  in  form.  In  forced 
respiration  the  excursion  may  reach  one  inch  or  more,, 
whilst  the  costophrenic  angle  may  descend  as  much  as 
two  inches.  Deep  inspiration  is  effected  by  increased 
action  of  the  inspiratory  muscles.  For  increased  activity 
during  expiration  only  relatively  weaker  muscular  power 
is  available ;  and  the  elastic  force  of  the  lung  increases  to 
a  slight  degree  only.  The  expiratory  position  of  the 
diaphragm  is  really  not  higher  than  in  quiet  respiration, 
indeed,  it  may  be  lower.  This  fact  explains  the  origin  of 
dilatation  of  the  lung  and  emphysema  as  the  result  of 
increased  inspiratory  activity  {vide  page  87). 

In  young  muscular  adults,  when  repeated  and  forced 
inspirations  are  taken  in  the  erect  posture,  the  incipient 
depression  of  the  dome  may  be  immediately  followed  by 
a  rise,  which  may  assume  a  higher  level  than  that  of 
expiration.  This  normal  paradoxical  effect  is  accompanied 
by  a  depression  of  the  epigastrium,  and  is  explained  by 
examination  in  the  lateral  position  The  posterior  part  of 
the  diaphragm  is  depressed,  as  usual,  by  contraction  of  the 
crura,  but  in  the  anterior  and  ventral  parts  the  powerful 
elevation  of  the  thorax  carries  with  it  the  costal  and  sternal 
attachments  of  the  diaphragm, "so  that  the  parietal  portions 
of  the  latter  appear  even  higher  than  the  dome,  even  in  the 
expiratory  position. 


Radiography  of  the  Chest  17 

When  the  diaphragm  contracts,  in  the  absence  of  activity 
of  the  intercostal  muscles,  as  in  faradisation  of  th^  phrenic, 
the  pleural  sinus  is  almost  completely  exposed.  This  is 
best  seen  on  the  right  side.  A  similar  condition  is  seen 
when  the  chest  is  held  in  a  rigid  position  (rigid  thorax) 
when  the  pleural  sinuses  become  almost  completely  filled 
by  the  lung.  This  is  accomplished  by  fixation  of  the  costal 
and  sternal  attachments ;  the  convexity  of  the  domes 
becomes  entirely  lost. 

The  outlines  of  the  mammary  glands  in  the  female  are 
often  visible  on  the  radiogram  ;  on  the  screen  they  may 
obscure  the  diaphragm  and  costophrenic  sinus.  They 
should  be  drawn  upwards.  A  fine  line  running  above  and 
parallel  to  the  clavicle  is  due  to  the  fold  of  skin  continued 
over  the  clavicle  from  the  neck.  In  strong,  muscular  men, 
the  lateral  edge  of  the  pectoralis  major  may  often  be 
followed  to  the  sixth  rib.  The  diminished  opacity  of 
cylindrical  shape  in  the  median  upper  part  of  the  chest  is 
due  to  the  trachea.  It  is  continuous  with  that  of  the  right 
bronchus,  and  the  latter  may  be  followed  as  far  as  the 
hilum.  The  left  bronchus  is  not  so  readily  traced,  since 
it  passes  in  front  of  the  descending  arch  of  the  aorta. 
Occasionally  the  nipples  appear  as  rounded  opacities  in  the 
middle  of  each  field.     (Radiogram  48.) 


l8  Radiography  of  the  Chest 


CHAPTER     11 

The  Classification  of  Pulmonary  Tuberculosis  : 
Tuberculosis  of  the  Bronchial  Glands 

A  FEW  introductory  remarks  concerning  the  varieties  of 
pulmonary  tuberculosis  are  necessary  before  undertaking 
a  description  of  their  prominent  radiological  features.  On 
account  of  the  pol^-morphism  of  the  disease ;  of  the 
propensit};'  of  the  bacillus  to  create  a  permanent  nidus 
within  the  pulmonary  organs,  and  its  disposition  to  invade 
the  surrounding  healthy  tissues,  insidiously  and  slowly, 
or  widely  and  tempestuously,  in  accordance  with  the 
alternating  phases  of  individual  resistance  and  susceptibility 
— invasive  attacks  which  are  often  followed  by  periods  of 
relative  or  even  perfect  calm,  during  which  the  defences 
of  the  organism  are  remobilised,  and  the  invalid,  v/ithout 
symptoms  .and  physical  signs,  may  be  apparently  cured  ; 
on  account  of  the  variability  in  quality  of  the  lesions,  their 
mode  of  onset,  and  evolution,  with  the  individual  diathesis 
and  period  of  life,  and  finally  by  reason  of  the  possible 
occurrence  of  separate  types  in  the  same  patient,  even  in 
the  same  lung,  a  satisfactory  classification  upon  any 
absolutely  rational  basis  appears  unattainable.  Certain 
interesting  groupings  of  the  disease  may  be  mentioned, 
e.g.,  that  which  records  the  method  of  onset  (insidious, 
pyrexial,  catarrhal,  haemoptoic,  dyspeptic,  enteritic,  chlo- 
rotic,  neurasthenic,  dyspnoeic,  influenzal,  bronchitic,  bron- 
chopneumonic,  pneumonic,  pleuritic).  Again,  Pegurier,  of 
Nice  (1903),  introduced  the  factor  of  resistance,  and 
classified  phthisis  into  three  principal  groups :  {a)  with 
active  and  adequate,  ib)  with  inconstant  resistance,  and 
(c)  in  which  the  resistance  is  nil.  These  classifications 
may  suggest  to  the  clinician  the  presence  of  the  disease 
concealed  under  general  manifestations,  or  may  call  atten- 


Radiography  of  the  Chest  19 

tion  to  the  connection  between  it  and  certain  abdominal 
functional  lesions,  due  apparently  to  reflex  irritation  of  the 
enteric  vagus, — occasionally  hypersecretion,  may  be  pyloric 
spasm  from  h^'peracidity ;  in  others  rapid  gastric  evacua- 
tion, appendicular  pain,  and  tachykinesis  of  the  small  and 
large  bowel.  Classifications  based  on  (a)  dyscrasias,  such 
as  gout,  rheumatism,  alcoholism,  syphilis,  and  diabetes  ; 
and  (b)  on  the  period  of  life,  such  as  infancy,  adolescence, 
adult  life,  and  old  age,  possess  but  a  subsidiary  utility  ; 
nevertheless,  they  may  remind  the  clinician  of  the  t3pe  of 
disease  most  frequently  to  be  expected  under  the  above 
conditions  :  for  instance,  in  alcoholism,  disseminated  nodal 
disease  with  fibrosis ;  in  diabetes,  a  rapid  disease  with 
large  excavations,  little  pyrexia  and  expectoration,  and 
possibly  no  night  sweating ;  in  gout,  scrofula,  and  rheu- 
matism, often  a  mild  attenuated  type.  With  regard  to  age, 
during  infancy  it  suggests  the  prevalence  of  tuberculous 
bronchoadenitis,  sometimes  in  the  shape  of  large  tumours; 
of  acute  bronchopneumonic  nodal  tubercle,  generally  of 
perihilar  origin  ;  of  generalised  miliary  tuberculosis,  and 
in  the  very  young,  of  the  acute  caseating  pneumonic 
variety  ;  of  apical  disease,  only  after  the  second  dentition 
and  the  approach  of  puberty,  as  a  general  rule  ;  in  adol- 
escents, of  galloping  phthisis  of  different  types  ;  in  middle 
life,  of  the  various  modalities  of  the  fibroid  lung;  in  old 
age,  of  the  very  slowly  progressive  fibroid  cavitary  forms, 
ending  sometimes  in  subacute  bronchopneumonic  nodal, 
in  pneumonic  lobar,  or  in  miliary  localised  dissemination. 
In  the  "Nomenclature  of  Disease"  (Royal  College  of 
Physicians,  19 18),  pulmonary  tuberculosis  is  divided  into 
(a)  acute,  and  {/»)  chronic.  The  acute  disease  is  further 
subdivided  into  (i)  miliary,  (2)  bronchopneumonic,  and 
(3)  pneumonic  ;  the  chronic  into  (i)  caseous,  (2)  fibroid, 
and  (3)  fibrocaseous;  each  of  the  latter  three  with  or  without 
excavation.  This  clinico-pathological  classification  is 
unsatisfactory,  since  miliary,  bronchopneumonic,  even 
pneumonic,  may  become  chronic ;    moreover,  many  cases 


20  Radiography  of  the  Chest 

of  caseous  phthisis,  included  under  the  heading  of  chronic 
disease,  may  become  rapidly  acute. 

Bard  bases  his  classification  on  the  anatomical  and 
topographical  distribution  of  the  lesions,  according  to  the 
particular  pulmonary  entity  chiefly  involved,  e.g.,  lobule, 
connective  tissue,  bronchus,  and  subpleural  tissue  ;  that  is, 
{a)  parenchymatous,  (b)  interstitial,  (c)  bronchial,  {d)  post- 
pleuritic.  Among  the  parenchymatous  forms  he  differ- 
entiates : — 

(a)  Mild  attenuated  cases  (apical  cicatrices,  etc.). 

{b)  Progressive  forms. 

1.  Caseating  types — 

{a)  Pneumonia  caseosa. 

{b)  Pneumonia   caseosa   extensiva   (phthisis 
galoppans). 

2.  Fibrocaseating  type,  ordinary  phthisis. 

3.  Fibroid  forms  (Chap.  VI), 

B.  In  the  interstitial  are  included  the  miliary  forms,  viz., 

{a)  general  (generalisata) ;  (^)  localised  (discreta  vel 
benigna) ;  (c)  migratory  (migrans),  attacking  several 
organs  in  succession  ;  {d)  suppurative  ;  and  {e)  the 
typho-tuberculosis  of  Landouzy  ("  La  Presse  Medi- 
cale,"  October,  1908  and  November,  1909). 

C.  In  the  bronchial  category  are  included,  (a)  tuberculous 

capillary  bronchitis ;  {b)  tuberculous  broncho- 
pneumonia ;  (c)  tuberculous  bronchiectasis  ;  {d) 
bronchitic  or  asthmatic  phthisis,  with  emphysema. 

D.  In  the  post-pleuritic  division  are  included  fibroid  as 

well  as  fibrocaseating  forms  (Chapters  VI  and  VIII). 
In  1899,  Turban  introduced  a  classification  based  on  (i) 
the  extent,  and  (2)  the  seriousness  of  the  lesions,  and  dis- 
tinguishes three  stages,  namely,  (i)  slight  lesions  reaching 
the  magnitude  of  one  lobe  only  at  the  outside ;  (2)  lesions 
more  extensive  but  not  exceeding  that  of  two  lobes,  or 
severe  lesions  affecting  the  extent  of  one  lobe  ;  (3)  all  lesions 
more  extensive  than  2.  The  area,  corresponding  to  that 
of  the  right  upper  lobe,  is  selected  as  defining  the  extent 


Radiography  of  the  Chest  2r 

of  one  lobe ;  it  may  be  represented  by  the  halves  of  two 
lobes,  or  the  thirds  of  three  lobes.  By  a  mild  affection  is 
understood  disseminated  foci,  with  slight  impairment  of 
percussion  note,  weak  breath  sounds  or  harsh  breathing, 
fine  or  medium  rales.  Severe  lesions  are  represented  by 
compact  infiltrations  containing  excavations.  At  the  Inter- 
national Congress,  at  Washington  (1908),  a  modification  of 
this  classification  was  suggested.  The  stages  again  were 
three  in  number,  of  which  in  the  first  there  are  lesions 
limited  to  small  areas  of  one  lobe,  for  instance,  not  reach- 
ing below  the  spine  of  the  scapula  and  the  clavicle,  if 
bilateral,  bounded  by  the  second  rib  in  front  if  unilateral ; 
(2)  areas  more  extensive  but  not  exceeding  the  magnitude 
of  one  lobe,  or  a  severe  affection  extending  to  half  one 
lobe ;  (3)  all  lesions  exceeding  the  second  degree,  or  with 
excavations.  The  difficulty  of  these  classifications  lies  in 
the  delimitation  of  the  magnitude  of  the  lesion  by  means 
of  physical  examination — this  can  only  be  done  thoroughly 
by  stereo-radiography — also,  the  precise  extent  of  a  lesion 
is  no  guide  to  its  attributes,  and  the  qualifications,  slight 
and  severe,  are  inadequate.  Finally,  no  attention  is  paid 
to  the  perihilar  lesions  unmasked  by  radiography. 

A  further  advance  was  made   by   Frankel  (19 17),   who 
distinguished  : — 

{a)  Indurative,  fibroid  healing  examples. 
{b)  Nodal  peribronchial  progressive  cases 
{c)  Caseative  pneumonic  or  bronchopneumonia  con- 
ditions. 
In  each  case  prognosis  is  rendered  unfavourable  by  the 
presence  of  excavations.     For  the  "closed  "  non-bacillary 
types  the  "plate"  alone  is  decisive  for  diagnosis  (Frankel). 
From  a  pathological  standpoint   Nicol  describes  (a)  con- 
glomerate,  and    {b)   confluent    forms.     In    the   former  are 
included    nodal    and     lobulo-bronchopncumonic,    in    the 
latter  lobar  pneumonic  and  lobar  fibroid  manifestations. 

For  the  purposes  of  radiography  the  types  of  phthisis 
are  now  described  in  the  following  order  : — 


22 


Radiography  of  the  Chest 

I.  Tuberculous  disease  of  the  bronchial  glands. 
II.  Disseminated  nodular  phthisis. 

III.  Disseminated  nodal  phthisis. 

IV.  Bronchopneumonic  pseudo-lobar  tuberculosis. 
V.  Chronic  attenuated  phthisis. 

VI.  Fibroid  phthisis. 
VII.   Pneumonic  phthisis. 
VIII.   Miliary  tuberculosis. 

Diagram  4. 


In  Chapter  VIII  remarks  will  be  found  re  post-pleuritic 
as  well  as  bronchitic  phthisis  ;  and  in  Chapter  IX  on 
diagnosis  observations  concerning  quiescent,  arrested  and 
quasi-arrested  disease. 

Tuberculous  Disease  oj  the  Bronchial  Glands. 

The   bronchial    glands    form    the    principal    anatomical 

substratum  of  intrathoracic  tuberculous   infection  in   the 

latter  part  of  the  first  and  the  earlier  3-ears  of  the  second 

decade  (5-15).     Their  general  topography  is  indicated  in 


^ 


o 


Facing  p.  23. 


Radiography  of  the  Chest  23 

Diagram  4.  It  is  seen  that  three  groups  are  distinguish- 
able:  (a)  mediastinal,  (b)  hilar,  and  (c)  perihilar.  The 
mediastinal  group  are  again  subdivisible  into  tracheo- 
bronchial (a,  Diag.  4),  and  the  bifurcation  glands,  (d,  Diag.  4). 
The  tracheobronchial,  bifurcation,  and  hilar  glands  may  be 
affected  singly  or  simultaneously ;  lesions  of  the  tracheo- 
bronchial and  bifurcation  glands  may  lead  finally  to  the 
production  of  tuberculous  mediastinitis.  When  hyper- 
trophied  and  inflamed  the  glands  become  visible  as  faint 
shadows  outside  their  topographical  loci-opacities  which 
become  more  intense  when  caseation  or  fibrosis  subse- 
quently occurs.  The  deepest  contrast  is  exhibited  when 
calcification  takes  place.  Intrathoracic  caseating  ;  lands 
form  a  continual  menace  to  life  ;  they  are  generally  present 
in  tuberculous  meningitis,  and  in  many  instances  they 
constitute  the  primary  focus  of  this  disease. 

Of  the  various  groups  the  bifurcation  glands  appear  to 
be  the  most  frequently  affected.  Their  position  behind 
the  cardiac  base  conceals  them  in  the  anterior  and  posterior 
positions  ;  in  order  to  visualise  and  radiograph  them  the 
right  anterior  oblique  diameter  is  necessary.  On  the 
radiogram,  for  the  purposes  of  diagnosis  the  divisions  of 
the  trachea,  that  is  the  two  chief  bronchi,  should  be 
discernible  with  the  opacity  between  them.  The  glands 
lie  principally  along  the  inferior  border  of  the  right 
extra-pulmonary  bronchus,  and  are  only  separated  from 
the  right  pulmonary  artery  b}'  the  pericardium.  Posteriorly 
they  lie  on  a  level  with  the  fifth  dorsal  spine.  The^' 
receive  lymphatics  from  the  lower  lobes  and  part  of  the 
rii^ht  middle  lobe.  The  left  tracheobronchial  (intrathoracic 
paratracheal)  come  into  close  contact  with  the  left  re- 
current laryngeal  nerve  (d).  They  are  separated,  to  some 
extent,  from  the  main  bronchus  running  to  the  left  lung 
by  the  left  branch  of  the  pulmonary  artery  (e) ;  on  the 
right  side,  consequently,  there  is  a  more  direct  communica- 
tion between  the  right  tracheobronchial  group  and  the 
right  hilar  glands   and  those  situated  along  the  bronchus 


24  Radiography  of  the  Chest 

of  the    right    upper   lobe   and    its    ramifications    (R.U.L. 

Dig.  4). 

Case  i. — Radiogram  4  (posterior).  On  the  right  of  the  spine, 
just  beneath  the  sternal  end  of  the  clavicle,  there  is  a  dark  shadow 
with  a  well  detined  border.  In  the  right  hilum  a  deep  opacity 
containing  a  lighter  area — the  right  bronchus.  On  the  left,  in 
the  fourth  posterior  interspace,  a  convex  shadow  between  the 
aorta  and  tlie  left  edge  of  the  heart.  Post-mortem  examination : 
in  the  right  hilum  a  number  of  caseating  glands  aggregated 
together  ;  above  the  right  hilum,  overhanging  the  superior  vena 
cava  and  the  right  innominate  vein,  a  caseating  gland — one  of  the 
tracheobronchial  group,  about  the  size  of  a  walnut.  Above  the 
left  hilum  a  gland  about  the  size  of  a  hazel  nut,  which  surrounds 
the  back'  of  the  left  bronchus,  and  contains  caseating  and 
calcareous  debris. 

Case  2. — Radiogram  5.  Clinical:  Percussion  note  slightly  im- 
paired at  the  right  apex,  otherwise  clinical  signs  normal ;  diarrhoea, 
the  stools  containing  tubercle  bacilli.  In  the  radiogram  there 
is  an  opacity  within  the  fifth  left  interspace  near  the  cardiac 
shadow.  Closely  adjacent  to  it,  within  the  fourth  and  sixth  spaces, 
small  foci  are  present  with  defined  contours.  Diagnosis  :  circum- 
scribed induration  (glands  ?)  in  the  left  hilum.  Post-mortem  :  in 
the  neighbourhood  of  the  left  hilum,  and  corresponding  in  position 
and  extent  to  the  shadows  on  the  plate,  indurated  lung  tissue  is 
found  containing  small  calcareous  foci.  In  both  hila  several 
anthracotic  and  partially  calcareous  glands.  The  left  hilar  opacity 
is  due  to  induration  of  the  pulmonary'  tissue  and  not  to  diseased 
glands.  The  opacities  surrounding  it  are  produced  by  small 
indurated  glands  containing  calcareous  material.  (Tuberculous 
foci  and  induration  in  the  left  perihilum.)  For  a  similar  case,  vide 
Radiogram  44. 

Case  3. — Radiogram  6.     Florence T ,  a;t.  12.     Clinical:  was 

in  good  health  until  three  years  ago,  when  the  glands  in  the  neck 
began  to  swell  :  there  is  cough  :  occasional  night-sweats : 
hiemoptysis :  physical  signs  withni  the  lungs  indefinite  :  right 
parasternal  dulness  (?).  In  the  radiogram  there  are  enlarged  and 
caseating  glands  in  the  right  paratracheal  group  :  some  increased 
shadowing  within  the  right  hilum,  continued  along  the  lower 
bronchus  :  a  slight  paratracheal  shadow  on  the  left  side,  and  a  few 
caseating  glands  in  the  left  hilum. 

Case    4. — Radiogram  7.     Clara  M ,   let.    21  :    has   suffered 

from  cough  for  some  years  :  since  influenza,  live  months  ago,  it 
has  been  worse  :  expectoration  scanty  :  wasting  4- '•  night  sweats  +  : 
breath  sounds  harsh,  right  apex.  Clinical  diagnosis  undetermined: 
The  Radiogram  shows  polyglandular  caseation  and  calcitication. 
Outside   the   right   border    of   sternum   a   faint  shadow  with    an 


o  .z: 


-  a 
-J  o 


'^  c 


Facing  p.'24. 


Radiography  of  the  Chest  25 

external  limit  running  parallel  with  sternum,  and  containing  within 
it  deeper  opacities :  one  marked  caseating  gland  with  calcareous 
spots  (arrow)  at  lower  part  of  right  hilum  :  twin,  calcareous 
opacities  in  right  middle  lobe  near  axillary  lines  (Ghon's  primary 
focus  ?)  :  some  indurations  along  bronchi  of  right  upper  lobe  : 
calcareous  and  caseating  opacities  at  the  left  hilum,  and  one  long 
cylindrical  calcareous  opacity  at  the  level  of  left  clavicle  at  its 
junction  with  the  sternum.  Phrenic  leaflets  uneven — irregular 
contraction  of  muscular  fibres  (?):  some  dilatation  of  the  right 
auricle.     A  small  lead  disc  over  left  nipple. 

Case  5. — Radiogram  8.     Alice  P ,  set.  16  :  suffers  from  cough 

and  night  sweats  :  is  thin,  anaemic  :  menstruation  is  delayed  :  there 
is  no  clubbing.     Physical  si^ns  :  right  paravertebral  dulness  (Ewart) 

Diagram  5. 


to  percussion,  and  double  parasternal  (4  cm.  on  right,  and  5  cm. 
on  left-normal  2  cm.):  both  apical  areas  (Kronig)  narrow,  at  this 
age  normal  is  4  cm.  :  breath  sounds  blowing  at  tlie  right  apex,  in 
the  upper  back  and  down  the  spines  to  the  third  dorsal,  with 
whispering  pectoriloquy:  breath  sounds  blowing  at  the  left  apex, 
but  less  than  on  the  right :  a  few  "  crackles,"  on  deep  breathing, 
over  the  right  base  in  front,  and  the  left  base  behind  :  no  other 
adventitious  sounds:  reflex  bands  of  impairment  to  percussion 
(Riviere).  Clinical  diagnosis:  tuberculous  bronchoadenilis  with 
some  hilar  tubercle.  The  radiogram  shows  enlargement  and 
caseation  of  all  the  central  groups  of  glands,  right  and  left 
paratracheal,  hilar,  and  in  the  right  oblique  radiogram  the  bifurca- 
tion glands.  Some  dissemination,  and  slight  contraction  of  chest 
along  the  axillary  lines  in  right  upper  and  middle  lobes.  Some 
dilatation  of  the  bronchi  at  the  bases.  Right  supraclavicular  apex 
somewhat  darker  than  the  left. 


26  Radiography  of  the  Chest 

Case  6. — Radiogram  9.  Joseph  Y — — ,  let.  1 2  :  cough,  dyspnoea, 
weakness :  he  has  always  been  dehcate  :  complexion  pale  :  palpable 
glands  are  present  in  the  axilke,  in  the  anterior  and  posterior 
triangles  of  the  neck.  These  are  firm  and  discrete  :  spleen  just 
palpable:  blood-count,  4,200,000  red  :  10,800  white:  haemoglobin, 
80  per  cent :  polymorphs,  53  per  cent.  :  lymphocytes,  47  per  cent. : 
small,  36  per  cent,  (lymphocytosis) :  (diminished  polynucleosis  and 
increased  lymphocytosis  characteristic  of  abortiv^e,  that  is,  attenuated 
tuberculosis) :  temperature,  97"6°  to  98°  :  Physical  signs  :  percussion 
note  over  left  upper  lobe  impaired  in  front  and  behind :  breath 
sounds  harsh  and  expiration  prolonged  :  vocal  resonance  increased  : 
over  the  rest  of  the  lungs  breath  sounds  diminished,  as  well  as  the 
vocal  resonance.  The  radiogram  (anterior)  shows  massive  hilar 
shadows,  some  containing  dark  granules  (calcitication)  :  calcified 
glands  in  left  axilla :  convex  paratracheal  shadow  below  sternal 
end  of  right  clavicle  :  and  a  smaller  opacity  below  the  left  clavicle 
on  the  mediastinal  border :  glands  obviously  enlarged  and  fibro- 
calcareous.  In  right  oblique  diameter  bifurcation  opacities  and 
glands  along  internal  mammary  also  enlarged :  tuberculous 
mediastinitis  :  some  basal  emphysema.  A  small  leaden  square  on 
each  nipple. 

Case  7. — Radiogram   10.     Ethel  G ,   set.    19:  cough,   night 

sweats,  no  hccmoptysis  :  Clinical :  a  few  rales  at  right  apex  and 
superior  angle  of  right  scapula  :  distended  abdomen,  fulness  in 
iliac  fossa,  and  diarrhoea :  stools  not  examined  for  bacilli.  The 
radiogram  exhibits  horizontal  ribs  and  emphysema:  a  slight 
costophrenic  adhesion  on  the  left  (radioscope).  The  arrow  points 
to  the  inverted  comma,  the  prolongation  of  which  upwards  marks 
the  right  border  of  the  trachea  :  the  comma  is  evidently  an  en- 
larged often  fibrosed  tuberculous  gland:  there  are  slight  para- 
tracheal shadows  on  each  side  of  the  upper  sternum,  and  some 
dissemination  betraying  itself  by  the  presence  of  thin  shadows  in 
the  peripheral  fields,  especially  in  the  right  costophrenic  angle, 
and  an  opacity  in  the  lower  periphery  of  the  right  hilum. 

Case  8. — 'Miriam  F ,  aet.  28  :    has  been  confined  to  bed  in 

hospital  six  months,  with  more  or  less  continuous  pyrexia,  ranging 
between  102°  and  99°:  family  history  is  negative:  the  illness 
commenced  with  rheumatic  pains  in  the  joints,  which  became 
swollen,  and  with  diarrhoea :  chest  signs  practically  nil,  with  the 
exception  of  harsh  breathing  and  prolonged  expiration  at  the 
apices,  and  granular  breathing,  almost  inspiratory  crepitations  in 
the  right  axilla,  also  marked  basal  annular  emphysema.  Emacia- 
tion extreme.  The  Radiogram  (11)  shows  massive  hilar  shadows 
and  fibroid  infiltrations,  especially  on  the  left,  and  some  pulmonary 
dissemination  on  both  sides  :  a  patch  of  fibro-calcareous  opacity  in 
the  right  axilla,  not  so  well  seen  in  print  as  in  the  plate  :   a  few 


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Radiography  of  the  Chest  27 

glands  outside  chest  in  right  upper  axilla,  also  not  seen  in  print : 
and  a  few  calcareous  foci  scattered  irregularly  in  the  apices  and 
right  middle  lobe.  The  chest  tends  to  the  thorax  paralyticus. 
The  case  raises  the  question  of  the  relations  between  certain 
forms  of  rheumatism  and  tubercle  (Poncet  and  Leriche).  The 
association  of  granular  breathing  and  hbro-calcareous  deposits  in 
the  right  axilla  suggests  that  rhe  former  is  not  always  a  sign  of 
incipient  tubercle,  but  may  really  be  an  indication  of  arrested 
disease.  The  radiogram  represents  chronic  tuberculous  media- 
stinitis. 

Case  9. — Mary  F ,  ait.   25  :  about  six  years  ago   suffered 

from  apical  trouble  which  healed :  about  three  years  ago,  after 
measles,  enlargement  of  the  cervical  glands  began  in  the  thyroidean 
region,  and  extended  to  the  posterior  triangle  :  these  are  painful 
and  chiefly  on  the  left  side  :  the  isthmus  of  the  thyroid  is  en- 
larged :  the  eyeballs  are  prominent :  Graefe's  sign  absent :  pupils 
rather  dilated  and  not  very  sensitive  to  light :  double  parasternal 
and  right  paravertebral  duluess  (Ewart)  is  present :  no  added 
sounds,  except  Heeting  clicks  at  the  right  apex  on  deep  breathing: 
there  is  slight  bronchial  breathing  and  increased  tactile  fremitus 
and  vocal  resonance  at  the  axillary  end  of  the  right  clavicle :  a 
faint  systolic  bruit  over  third  left  interspace  (anaemic) :  pulse,  76-90 : 
blood  pressure,  125  mm.:  palpitation,  flushes,  and  occasionally 
frontal  headaches.  The  Radiogram  (12)  shows  tracheobronchial 
opacities  on  each  side:  and  iuliltration  of  each  hilum,  especially 
the  left,  with  some  fibrosis  of  this  side.  The  case  is  interesting, 
since  it  shows  the  revival  of  central  tubercle,  and  of  the  glands 
in  the  neck,  after  an  attack  of  measles,  as  a  cervical  and 
endothoracic  adenitis.  In  the  blood  there  is  increased  poly- 
nucleosis, and  diminished  lymphocytosis,  indicating  that  tubercle 
is  still  in  play.  The  enlargement  of  the  thyroid,  the  tachycardia, 
the  Hushing  and  prominence  of  the  eyeball  suggest  Graves'  disease 
of  a  mild  form.  It  is  quite  common  to  fuid  an  increased  right 
paratracheal  opacity,  or  the  remains  of  a  massive,  almost  general 
infection  of  the  lung  itself  in  subjects  of  this  disease :  occasionally 
attacks  of  exoj")htlialmic  goitre  occiu-  simultaneously  with  ex- 
acerbations of  pulmonary  tubercle :  also  in  soldiers  exhibiting 
the  signs  of  hyperthyroidism,  paratracheal  shadows  may  be  present. 
The  relations  between  the  two  diseases  are  still  obscure,  and 
require  further  investigation.  At  least  every  case  of  exophthalmic 
goitre  should  be  radiographed,  and  if  the  glands  or  the  Ihynnis 
arc  found  enlarged.  X-ray  treatment  should  be  at  the  same  time 
administered  to  these  structures. 

Case  10. — Robert   P ,  x't.  21,  suffers  from  enlargement  of 

cervical  glands  in  both  posterior  triangles,  especially  on  the  left 
side,  and  both  axilke,  and  there  is  one  large  supraclavicular  gland 


28  Radiography  of  the  Chest 

on  the  left.  The  glands  are  firm:  there  is  pyrexia  and  some 
wasting:  Clinical  signs :  there  is  slight  impairment  of  percussion 
resonance  over  the  right  chest  front  and  back,  and  a  right 
paravertebral  dulness,  with  some  line  crepitations  at  the  right 
base.  The  posterior  radiogram  shows  pleural  thickenings  at  both 
supraclavicular  apices,  especially  the  left :  a  faint  paratracheal 
shadow  on  the  right  side,  otherwise  the  lungs  are  normal.  In  the 
right  oblique  radiogram  (Radiogram  13)  the  faint  paratracheal 
shadow  is  indicated  by  the  middle  arrow  :  the  highest  arrow  points 
to  the  tail  of  the  comma,  which  is  evidently  a  thickened  lymphatic, 
and  here  indicates  the  posterior  margin  of  the  trachea :  the  lowest 
arrow  indicates  the  bifurcation  opacity  between  the  limbs  of  the 
main  bronchi. 

In   very  young  children  the  central  glands  may  become  very 

large.     Grace  B ,  :jet.  2^   years :    family  history  is  negative : 

suffered  from  measles  and  bronchitis  eight  months  ago,  and  has 
never  been  well  since  :  there  is  a  paroxysmal  cough  without  whoop  : 
no  expectoration :  loss  of  appetite  :  night  sweating  about  the 
head:  no  pyrexia:  temperature  generally  subnormal.  Clinical 
iigns  :  right  apex,  impaired  note  :  vocal  vibrations  and  resonance 
increased :  bronchial  breathing  and  crepitations  :  slight  collapse 
of  the  right  chest  :  child  was  discharged  in  statu  quo  after  six 
weeks.  Clinical  remarks  :  "  The  diagnosis  of  collapsed  upper  lobe 
due  to  tuberculous  mass  of  glands  pressing  on  right  upper  bronchus 
unlikely  owing  to  absence  of  stridor  and  the  presence  of  added 
sounds :  the  clinical  diagnosis  therefore  remains  doubtful." 
Pirquet  evidently  not  employed.  Radiogram  14  (posterior)  a 
large  wedge-shaped  opacity,  apex  below,  is  present  along  the 
right  side  of  trachea  and  right  bronchus  (paratracheal),  outside 
which,  in  the  right  upper  lobe,  there  are  signs  of  dilated  tubes  and 
slight  infiltration.  The  left  hilum  shows  an  opacity  of  increased 
magnitude  and  intensity.  On  the  right  the  shadow  is  uniformly 
opaque.  Radiological  diagnosis  :  caseating  tracheobronchial  glands 
on  the  right  producing  an  opaque  mass  in  the  radiogram,  and 
leading,  by  compression  of  right  bronclius,  to  incipient  fibrosis  of 
right  upper  lobe.  Bifurcation  glands  in  the  right  oblique  position 
unaffected. 

Radiograms  Nos.  15  and  16  are  inserted  in  order  to 
show  the  softening  and  final  irruption  of  hilar  caseating 
glands  into  the  lung.  This  patient  was  kept  under 
observation  for  about  one  year.  The  final  dispersal,  which 
produced  an  acute  nodular  bronchopneumonic  tuberculosis, 
occurred  a  few  weeks  before  death.  The  differential 
diagnosis  of  the  various  mediastinal  and  hilar  opacities, 
such   as  are  produced  by  mediastinal  tuberculous,  sarco- 


Kau.  14  (Post.)     Caseatiiig  right  iiaratraclical  opacity. 


Facing  p.  28. 


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Radiography  of  the  Chest  29 

matous  and  carcinomatous  growths,  b}''  enlargement  of  the 
thymus,  b}^  lymphadenoma,  aneurysmal  swellings,  is 
discussed  in  Vol.  II,  in  the  chapter  devoted  to  tumours  of 
the  lung  and  mediastinum. 

Clinical  and  Radiological  Remarks. — The  above  cases 
render  it  obvious  that  there  are  no  clinical  criteria  of  any 
value,  and  that  the  radiological  examination  is  necessary 
for  the  diagnosis  of  tuberculosis  of  the  bronchial  glands. 
Difficult  as  it  is,  in  the  case  of  the  child,  in  the  adult  it  is 
more  perplexing  still.  The  simultaneous  occurrence  of 
several  clinical  symptoms  may  render  the  diagnosis 
suspect.  These  are  parti}'  due  to  pressure  on  bronchi, 
blood  vessels,  lymphatics,  nerve  trunks  and  plexuses,  and 
partly  due  to  the  absorption  of  toxins  'produced  by  the 
virus.  The  glands,  however,  very  rarely  become  tumours 
of  sufficient  size  to  produce  marked  pressure  S3'mptoms, 
unless  very  favourably  situated,  and  some  of  these  effects 
may  in  reality  be  due  to  reflex  influences  exercised  on  the 
external  inspiratory  muscles  and  the  diaphragm.  Very 
occasionally  the  bifurcation  glands  may  become  large 
enough  to  compress  the  oesophagus  and  induce  difficulty 
of  swallowing  (one  case — the  author),  or  they  may  soften 
and  become  evacuated  by  this  channel.  Occasionall}^ 
enlarged  paratracheal  glands  on  the  left  compress  the 
recurrent  nerve,  producing  hoarseness  and  sometimes  loss 
of  voice;  the  paroxysmal  cough  may  be  due  to  compres- 
sion of  the  vagus  or  to  mechanical  irritation  of  the  lining 
of  the  chief  bronchi  and  trachea  near  its  bifurcation.  In 
children  it  is  usual  to  lay  stress  on  the  presence  of  whis- 
pering pectoriloquy  in  the  paravertebral  regions  of  the 
chest  and  dorsal  spines  ;  to  signs  of  pain  on  pressure  upon 
the  spinal  processes  of  the  upper  dorsal  vertebrae,  which 
may  be  very  occasionally  met  with  ;  to  the  presence  of  an 
increased  Ewart's  area  of  paravertebral  dulness,  and  harsh 
blowing,  or  even  weakened  apical  breath  sounds,  with 
perhaps  an  occasional  click  (oedema?)  at  the  end  of  a  deep 
inspiration. 


30  Radiography  of  the  Chest 

With  the  formation  of  small  areas  of  perihilar  infiltra- 
tion, crepitations  may  be  heard  at  the  level  of  the  nipple, 
the  hila  behind,  or  these  may  be  conducted  to  the  axillae 
and  apices.  In  the  majority  of  cases  in  children  the  dis- 
semination is  purely  lymphatic,  the  lymph  trunks  become 
thickened,  and  the  pulmonary  glands  enlarge,  but  remain 
follicular,  and  do  not  become  infiltrative.  It  often  corre- 
sponds to  a  general  hyperplasia  of  the  lymphatic  glands, 
and  is  merely  a  passing  phase  of  temporary  loss  of  the 
powers  of  resistance,  which,  under  proper  treatment, 
rapidly  disappears.  Between  the  ages  of  5  and  15  the 
immunity  is  generally  sufficient  to  prevent  any  serious 
establishment  of  the  disease.  {Vide  Lancet,  Sept.  30th, 
191 7,  Overend  and  Riviere.)  When  the  presence  of 
pulmonary  tuberculo-adenitis  in  the  adult  is  suspected,  the 
presence  of  faint  bronchial  breathing,  of  rales,  or  sibili  in 
the  neighbourhood  of  the  hilum,  in  front  or  behind,  will 
make  the  diagnosis  more  probable.  Especially  will  this 
be  the  case  if  the  temperature  is  labile,  with  an  increased 
reaction  'after  work  and  exercise  ;  if  the  pulse  is  of  low 
tension  and  unstable,  becoming  easily  accelerated  ;  if  there 
is  a  paroxysmal  cough,  and  if  the  patient  shows  signs  of 
anaemia,  lassitude,  or  neurasthenia.  The  clinical  signs 
may  be  due  to  a  localised  congestive  bronchopneumonia, 
or  actually  to  a  hilar  or  perihilar  tuberculosis.  The  pro- 
bability, as  in  children,  is  in  favour  of  the  former.  A  good 
radiogram  may  prove  illuminative,  and  is  the  only  certain 
method  of  diagnosis. 

Some  of  the  cases  in  children  of  school  age,  as  mentioned 
above,  exhibit  on  the  radiogram  the  presence  of  a  general 
hypertrophy  of  the  tracheo-broncho-pulmonary  lymphatic 
tract,  and  quite  small  nodules  may  even  be  seen  just 
beneath  the  pleura.  There  may  be  a  fine  narrow  shadow 
running  parallel  to  the  sternum  on  the  right,  and  both 
hilar  areas  assume  a  diffuse  gray  appearance.  In  addition, 
the  cervical  axillary  (and  possibly  the  mesenteric  glands) 


Radiography  of  the  Chest  31 

are  enlarged  and  palpable.  These  are  accompanied  by 
malaise,  anaemia,  and  later  by  amenorrhoea. 

Hyperplasia  of  the  central  lymphatic  glands,  both  in 
children  and  in  adults,  may  be  due  to  causes  other  than 
tubercle.  Enlargement  may  accompany  simple  chronic 
bronchitis,  lobular  and  lobar  pneumonia,  in  particular  that 
which  accompanies  measles  and  pertussis,  also  the  rare 
adult  form  of  fibrinous  bronchitis,  and  certain  neoplasms 
of  the  mediastinum.  In  some  instances,  as  well  as  in  mild 
tuberculous  infections,  the  effects  of  forced  inspiration 
during  cough,  aided  by  a  presumed  deficiency  of  elasticity 
in  the  pulmonary  tissue,  may  be  shown  by  the  production 
of  a  generalised  cylindrical  bronchiectasia  and  of  emphy- 
sema, with  their  proneness  to  attacks  of  recurrent  bron- 
chitis, and  which,  if  the  tuberculous  contagion  becomes 
negligible,  assume  the  predominant  features.  The  pressure 
of  enlarged  paratracheal  and  bifurcation  glands  on  the 
bronchi  may  lead,  as  in  other  forms  of  compression,  as 
those  of  neoplasm  and  aneurysmal  swellings,  to  the  pro- 
duction of  pulmonary  fibrosis  beyond  the  seat  of  compres- 
sion, and  conversion  of  the  offending  mass  into  innocuous 
fibrous  tissue  will  not  necessarily  restore  the  integrity  of 
the  upper  lobe,  which  in  the  meantime  has  become  cirrhotic 
and  is  occupied  by  dilated  tubes.  In  other  cases  an  un- 
resolved basal  lobular  or  lobar  pneumonia  may  finally 
become  fibrosed,  then  bronchiectatic,  and  this  may  be 
bilateral.  A  radioscopic  examination  at  once  demonstrates 
the  presence  of  a  basal  triangular  opacity,  with  its  apex  at 
the  hilum  and  its  base  occupying  all,  or  nearly  all,  one 
moiety  of  the  diaphragm.  It  may  be  termed  the  basal 
bronchiectatic  fold  or  triangle. 

Cases  of  unresolved  basal  pneumonia,  and  of  pure  fibroid 
lung  in  children,  are  often  sent  to  the  tuberculosis  dis- 
pensary to  be  treated  as  tubercle;  they  are,  in  reality,  more 
common  than  the  genuine  afiection.  We  return  to  this 
subject  in  the  chapter  on  "  Bronchiectasis  "  (Vol.  II).  It  is 
obvious,  however,  that  in  patients  suffering  from  general 


32  Radiography  of  the  Chest 

cyhndrical  bronchiectasia  the  prescription  of  respiratory 
exercises  may  do  more  harm  than  good,  if  undertaken 
before  the  pulmonary  elasticity  has  recovered.  This  type 
of  bronchiectasis  is  also  readily  diagnosed  by  radiography. 


Radiography  of  the  Chest  33 


CHAPTER   III 
Bronchopneumonic  Phthisis 
(Bronchopneumonia   Tuberculosa) . 
Bronchopneumonic   phthisis,    or   caseating  bronchopneu- 
monia, may  be  described  under  three  heads,  {a)  nodular, 
(b)  nodal,  and  (c)   pseudolobar,  according  as  the  foci  are 
quite  small  and  nodular,  or  larger  and  multilobular  (nodal). 
The  latter  may  fuse  and  produce  extensive  tracts  (pseudo- 
lobar), which  then  approach  in  appearance  the  pneumonic 
forms.     For  the  sake  of  convenience  this  t3'pe  is  described 
in  Chapter  IV. 

Bronchopneumonic  tubercle  is  the  classical  type  in 
children.  Both  in  children  and  in  adults  it  is  secondary  to 
primary  foci  already  present  within  caseating  hilar  glands, 
or  to  infiltrations  occurring  in  a  state  of  softening  or 
excavation  within  the  lung  itself  It  may  follow  influenza, 
one  of  the  infectious  fevers  (measles,  etc.),  and  diabetes;  it 
may  occur  in  women  exhausted  by  frequent  pregnancies 
and  by  the  repeated  nursing  of  children ;  also  it  may 
complicate  the  debilitated  conditions  produced  by  penury 
and  starvation. 

I.  Disseviinatcd  nodular  Phthisis. 
When  fragments  of  a  softened  caseous  gland,  or  portions 
of  a  caseating  dissolving  mass,  lying  in  an  apical  or  peri- 
hilar  cavity,  become  detached  and  obtain  access  to  the 
air  passages  in  larger  bulk  than  can  be  convenientl}'  and 
adequately  expelled  pari  passu,  bacilli  may  be  scattered  by 
inspiratory  efforts,  either  widely  throughout  both  lungs 
(general  dissemination)  or  may  affect  certain  areas  of  one 
or  both  lungs  alone  (partial  dissemination).  This  process 
of  dispersal,  which  may  accompany  the  periodic  exacerba- 
tions of  chronic  cavitary  pulmonary  tubercle,  and  may  be 
attended   by    slight    haemoptysis,  increased    cough    and 

D 


34  Radiography  of  the  Chest 

pyrexia,  plays  a  much  greater  role  in  the  evolution  and 
the  radiographical  topography  of  pulmonary  phthisis  than 
clinical  examination  suspects  or  is  able  to  reveal.  No 
period,  not  even  old  age,  is  exempt  from  its  possible 
occurrence,  provided  the  necessary  lesions  exist  within 
the  lung.  As  elucidated  by  radiograms,  it  appears  to  take 
place  in  the  adult,  perhaps  more  frequently  during  the 
third  and  fourth  decades  of  life.  Moreover,  isolated 
groupings  of  small  rounded  foci,  often  present  in  the 
lateral  areas  of  the  chest,  near  the  axillary  lines,  frequently 
owe  their  origin  to  a  similar  cause  ;  in  the  process  of  time 
these  may  become  inofifensive  fibroid  specks,  or  may 
vanish  altogether  from  view.  iGeneral  and  partial  dissemin- 
ation is  consequently  a  secondary  manifestation,  due  to 
the  persistent  and  fitful  activity  of  primary  foci,  situated 
either  within  caseating  glands  or  among  the  debris  of 
imperfectly  evacuated  cavities.  Such  disseminated  foci 
appear  as  grayish  white  nodules,  located,  in  recent  cases, 
at  the  extremities  of  the  bronchioles.  They  are  inde- 
pendent of  each  other  at  first ;  but  are  crowded  and  packed 
together  so  as  to  give  a  granular  appearance  to  the 
fluoroscopic  screen  and  to  the  lobules  as  seen  post-mortem. 
Primarily  of  the  size  of  a  grain  of  millet,  or  of  a  hemp 
seed,  they  may  rapidly  increase  in  size  and  become  as 
large  as  a  bean,  or  the  nodules  may  aggregate  to  form 
larger  opacities,  producing  finally  either  bronchopneumonia 
nodal  or  pseudolobar  infiltrations  {q.v.).  Careful  examin- 
ation of  a  satisfactory  radiogram  will  usually  discover 
the  presence  of  a  large  or  of  several  small  cavities,  with 
surrounding  infiltrations  on  one  or  both  sides,  about  the 
level  of  the  anterior  osseous  extremity  of  the  first  rib, 
within  the  axillary  areas,  or  in  the  depth  of  the  perihilum. 
These  cavities  may  not  present  the  aspect  of  old  thick- 
walled  extinct  excavations,  but  their  outlines  may  be  less 
definite,  irregular,  and  obviously  they  still  enclose  caseating 
material.  There  is  often  a  tendency  to  general  cylindrical 
dilatation  of  the  smaller  bronchi  (paresis  of  the  muscular 


—   -J 


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l-'aciriK  p.  34. 


Facing  p.  34- 


Radiography  of  the  Chest  35 

wall) ;  in  some  areas  the  foci  are  arranged  around  the 
circular  bronchial  transparencies;  in  others  they  stud  the 
bronchial  walls,  fortuitously  cut  in  their  long  axes,  and 
these  foci  may  coalesce  to  form  fibrocaseous,  ultimately 
fibroid  sheaths. 

The  severity  of  the  process  varies  within  the  widest 
limits.  Occasionally  the  condition  may  remain,  in  older 
patients  generally,  for  months  in  statu  quo,  and  a  second 
radiogram  may  reveal  minor  changes  only ;  in  others, 
where  the  bronchi  appear  little  affected,  and  no  fibrosis 
succeeds,  the  process  of  aggregation  and  infiltration 
advances  rapidl}'',  leading  to  extensive  confluent  pseudo- 
lobar  infiltrations,  and  a  fatal  issue  within  a  few  months. 
Even  in  the  widely  disseminated  cases  the  physical  signs 
may  be  indefinite.  The  percussion  note  may  be  slightly, 
if  at  all,  impaired,  or  there  may  bean  emphysematous  note 
(general  dilatation  of  small  bronchi  ?)  and  an  absence  of 
retraction  of  the  chest.  Auscultation  may  reveal  a  few 
doubtful  crepitations,  perhaps  at  one  apex  or  base,  or 
within  the  lateral  axillary  lines,  and  occasional  sibilant 
sounds.  Haemoptysis  is  rarely  profuse ;  it  may  be  a  mere 
staining  or  it  may  be  absent  altogether.  Cough  may  be 
persistent,  expectoration  trifling,  pyrexia  irregular  but  not 
severe,  and  night  sweats  may  cease.  The  expectoration 
may  contain  bacilli,  intermittently  in  accordance  with  the 
repeated  exacerbations.  Emaciation  in  some  instances  is 
pronounced.  Very  occasionally  a  local  pleuritic  effusion, 
perhaps  basal  and  axillary,  may  be  present. 

Case  i. — Walter  R ,  aet.  44  (2.7.18).     Clinical :  pain 

in  side  and  cough  for  ten  weeks :  wasting  + :  haemop- 
tysis +  :  began  in  pleurisy  three  months  ago  :  now  unable 
to  follow  his  employment :  right  apex  in  front  and  behind 
slight  impairment  of  percussion  note:  crepitations 
right  apex  :  in  left  lung  crepitations  in  mammary  region  : 
dulness  at  bases  behind.  Clinical  diagnosis:  phthisis 
and  pleurisy.  Radiogram  17:  disseminated  tubercle 
showing  patchy  aggregations  :  enlarged  hila  :  cavities  at 


36  Radiography  of  the  Chest 

right  apex  (only  visible  on  the  plate)  :  slight  emphysema 
of  both  lungs  and  general  cylindrical  dilatation  of  the 
bronchi. 

Case   2. — George    H ,  aet.   21  (9.4.18).      Clinical: 

cough  and  haemoptysis :  emaciation,  i  stone :  dyspnoea 
+  +  :  heart  apex  beat  normal :  movement  diminished 
and  slight  flattening  at  the  right  apex  :  crepitations  both 
apices.  Clinical  diagnosis:  pulmonary  phthisis — both 
apices.  Radiogram  18 :  shows  a  general  dissemination 
of  foci  throughout  both  lungs  :  small  excavations  in  the 
right  supraclavicular  apex  :  irregularly  located  aggrega- 
tions of  foci  in  the  right  lung :  an  extensive  broncho- 
pneumonic  infiltration  in  the  left  lung  :  enlarged  para- 
tracheal  glands  on  each  side  of  the  central  mediastinal 
opacity. 

Case  3. — William  G.  B ,  aet.  21  (9.4.18).     Clinical : 

cough  + :  haemoptysis  — :  emaciation,  2  stone:  night 
sweats  — :  movement  diminished  and  flattening  of  right 
chest :  crepitations  at  both  apices.  Clinical  diagnosis : 
double  apical  phthisis.  Radiogram  19,  contraction  left 
chest,  large  cavity  right  apex  with  a  central  more 
translucent  area  (bronchus  ?):  both  lungs  filled  with 
small  nodular  foci  apparently  becoming  arrested  on 
right,  rather  sparing  dispersal  of  foci  throughout  left 
lung  :  both  hilar  opacities  increased  in  area  and  density: 
nodal  opacities  in  left  hilum  :  some  emphysema  of  right 
lung. 

Case 4. —William  V ,  aet.   28.    Clinical:  t°  97°-98°^ 

Tbc.  + :  signs  of  infiltration  at  the  right  apex  and  of  fluid 
at  the  left  base  (where  breath  sounds,  vocal  fremitus  and 
vocal  resonance  are  absent).  Radiogram  20 :  general 
disseminated  foci  throughout  both  lungs  :  just  beneath 
the  middle  of  right  clavicle  an  infiltration  containing  less 
opaque  areas  (cavities)  :  some  of  the  foci  in  right  lung 
becoming  calcareous  or  fibroid :  left  basal  effusion,  not 
reaching  as  high  as  the  nipple  (metal  square) :  very 
slight  deviation  of  heart  towards  the  right  side.  The 
case  aff'ords  one  of  the  numerous  illustrations  of  the 
contrast  between  the  poverty  of  clinical  and  radio- 
scopical  and  the  wealth  of  radiographical  signs.  With 
the  fluorescent  screen  the  opacity  at  the  right  apex  and 


15 


m 


l-"acine  p.  36. 


Radiography  of  the  Chest  37 

the  small  basal  effusion  on  the  left  side  alone  were  visible 
thus  demonstrating  the  absolute  unreliability  of  radio- 
scopy per  se,  except  in  gross  lesions. 

In  the  chronic  or  subacute  cases,  the  fibrosis  becomes 
more  pronounced,  and  the  dissemination,  if  primarily  more 
or  less  general,  becomes  restricted  to  localised  areas. 

Case  5. — Frederick  B ,  aet.  60,  painter.     Cluneal: 

haemoptysis  frequent  and  small  in  amount :  cough  + : 
temperature  97°-98°:  Tbc.  + :  clinical  signs  chiefly  of 
emphysema  and  bronchitis.  Radiogram  21  :  small  cavi- 
ties within  the  left  supraclavicular,  and  apparently  two 
larger  in  the  infraclavicular  areas :  disseminated  small 
foci  in  the  lateral  part  of  the  left  lung :  calcified  rib 
cartilages. 

Case  6. — Leonard  S ,  aet.  23  :  ex-soldier.     Clinical : 

percussion  note  impaired  at  both  apices  :  weak  breath 
sounds  left  apex  :  crepitations  in  right  lung  :  no  pyrexia  : 
Tbc.  +  :  Clinical  diagnosis :  pulmonary  tuberculosis  of 
both  lungs.  Radiogram  22,  a  large  cavity  cut  by 
clavicle  on  right  side :  in  left  supraclavicular  apex  and 
upper  subclavicular  triangle  several  lighter  areas  :  fusi- 
form fibroid  bands  of  opacity  running  towards  left  hilum  : 
a  cavity  (pseudo?)  between  second  and  third  ribs  at  the 
left  axillary  border :  disseminated  foci  in  the  right 
middle  lobe  and  in  the  axillary  region  of  the  left  lung. 
Radiological  diagnosis:  chronic  fibroid  disseminated 
phthisis. 

Disseminated  Nodal  Phthisis. 

In  some  cases  the  nodal  foci  may  be  numerous,  closely 
packed  together  (Radiogram  23),  and  the  disease  is 
subacute.  One  sees  this  form  occasionally  in  middle-aged 
men  addicted  to  alcohol ;  when  well  defined,  it  may  be 
termed  the  inebriate's  lung.  In  others  the  nodal  infiltra- 
tions are  few,  the  progress  is  slow  and  may  become 
actually  arrested.*    Chronic  apical  andperihilar  infiltrative 

•  These  nodal  infiltrations,  when  radiographed  later,  often  pass  directly 
into  healed  patches  of  fibrosis.  This  transformation  is  dependent  upon  the 
nature  of  individual  resistance,  which  may  be  inherent  or  acquired. 


38  Radiography  of  the  Chest 

types  are  described  in  Chapter  iVI.  The  subacute  and 
chronic  dissemination  from  the  primary  caseous  focus  may 
be  partial  only,  or  advance  may  be  made  by  mere  con- 
tiguity, that  is,  by  the  passage  of  bacillary  sputum  along- 
the  walls  of  the  bronchi :  or  by  way  of  the  lymphatics.  In 
the  acute  types  aspiration  probably  plays  a  more  important 
role  by  carrying  the  bacilli  to  distant  parts  of  the  lungs. 
If  the  general  dissemination  occurs  at  a  time  when  the 
systemic  resistance  is  low,  the  foci  may  rapidly  enlarge 
and  produce  pseudolobar  infiltrations,  which  appear  as 
extensive  opaque  areas  on  the  radioscopic  screen,  pro- 
ducing an  acute  phthisis  of  short  duration. 

In  bronchopneumonic  nodal  types  the  cough  may  be 
frequent,  it  may  be  accompanied  by  a  greyish-white 
expectoration,  and  the  dyspnoea  may  become  far  more 
severe  than  is  warranted  by  the  meagre  physical  signs. 
There  may  be  small  scattered  areas,  in  some  cases,  of 
sibilant  or  subcrepitant  rales  ;  in  others,  localised  regions 
of  bronchial  breathing  and  bronchophony,  not  necessarily 
more  pronounced  towards  the  apices  :  loss  of  weight  and 
strength,  and  obvious  cyanosis.  The  diagnosis  rests  on 
the  examination  of  the  sputum,  and  on  the  radiogram.  In 
some  instances,  where  prolonged  pyrexia  occurs  in  cases 
of  creeping  or  wandering  influenzal  bronchopneumonia, 
where  cough  is  slight  and  expectoration  is  trivial  or 
unobtainable,  but  loss  of  strength  and  emaciation  are 
paramount,  it  is  only  when  cavitation  occurs,  and  this  may 
be  delayed,  or  when  caseating  foci  are  found  post-mortem 
in  the  bronchial  glands  or  elsewhere,  that  a  diagnosis  of 
tubercle  becomes  justified.  In  protracted  cases  of  delayed 
resolution,  after  bronchopneumonia  lasting  several  weeks, 
even  two  or  three  months,  the  radiogram  will  show 
unresolved  and  resolved  patches  of  bronchopneumonia 
side  by  side  in  one  lung,  or  resolved  areas  in  one,  and 
unresolved  areas  in  the  other  lung.  There  may,  however, 
be  signs  of  old  apical  tubercle,  and  the  family  history 
may  be  suggestive. 


u 


5  i^ 

-^  5 


34 


laciiiK  11.  38. 


Radiography  of  the  Chest  39 

Isaac  L ,  aet.   59,  complains  of  pains  in  the  left 

chest,  with  cough  which  has  lasted  for  three  months, 
and  of  emaciation.  Clinical  diagnosis :  emphysema, 
bronchial  catarrh,  arterio-sclerosis.  On  account  of 
difficulty  in  swallowing,  patient  was  sent  to  the  X-ray 
department  for  examination  of  the  oesophagus  by  means 
of  the  bismuth  bolus.  This  showed  spasmodic  con- 
traction at  the  level  of  bifurcation  of  the  trachea,  and 
again  lower  down  near  the  diaphragmatic  opening 
(tuberculous  laryngitis  ?).  On  account  of  suspicious 
fluoroscopic  appearances,  observed  during  the  progress 
of  deglutition,  a  radiogram  of  the  chest  was  taken,  in 
which  (Radiogram  23)  there  is  an  irregular  cavitation 
at  each  apex,  and  nodal  consolidations  are  present 
in  the  upper  lobe  of  the  right,  and  scattered  throughout 
the  whole  of  the  left  lung,  producing  a  characteristic 
dappled  appearance. 

For  comparison   the  following  case  of  influenza-pneu- 
monia is  included  : — 

Eliza  S ,  aet.  23,  had  a  severe  attack  of  influenza- 
pneumonia,  commencing  nine  weeks  ago.  There  is  a 
family  history  of  phthisis,  and  one  sister  is  now  in  a 
sanatorium.  The  pyrexia  is  still  oscillatory,  reaching 
101°  or  102''  of  an  evening,  with  morning  remissions: 
emaciation  is  severe,  but  cough  and  sputum  are  absent. 
It  was  suggested  that  an  encysted  empyema  might  be 
present,  but  the  clinical  signs  and  the  radiogram  nega- 
tive this  possibility.  The  latter  (Radiogram  24,  posterior) 
reveals  a  bronchopneumonic  irregular  consolidation 
affecting  chiefly  the  area  around  the  interlobe,  and 
showing  transparencies  due  to  dilated  tubes,  Crane's 
inverted  comma  along  the  right  side  of  the  trachea,  and 
partial  resolution  of  the  left  basal  bronchopneumonia, 
which  was  present  three  w-eeks  ago  in  the  first  radio- 
gram. There  may  have  been  an  apical  bronchopneu- 
monia as  well  on  the  left  side,  as  shown  by  the  small 
excavations,  and  a  slight  opacity  above  the  left  clavicle. 
On  the  other  hand,  the  lesion  at  the  left  apex  may  be 
tuberculous  :  if  this  is  the  case  the  prognosis  becomes 
unfavourable.  The  left  diaphragm  was  immobile.  Pyrexia 
gradually    abated  and   strength  returned   slowly   for  a 


40  Radiography  of  the  Chest 

time.     Subsequently  an   encysted  empyema  was  found 

radiologically,   which    was    treated    by    resection   and 

drainage.     The  patient  is  still  under  treatment  (22.7. 19).* 

An    example   of  chronic    localised    nodal    disease   is 

shown  by  Hilda  A ,  aet.  27  (Radiogram  25):  she  has 

suffered  from  cough  for  a  month,  with  small  haemoptyses 
on  several  occasions :  wasting  +  :  physical  signs  in- 
definite. The  radiogram  shows  several  broncho- 
pneumonic  nodal  opacities,  in  the  right  supraclavicular 
apex,  over  the  first  right  rib,  and  in  the  first  right 
anterior  interspace,  also  several  in  the  base  of  the  right 
upper  lobe,  a  few  in  the  left  upper  lobe,  and  a  condition 
of  diffuse  cylindrical  bronchiectasia,  especially  in  the 
right  lung.  There  are  indistinct  signs  of  a  cavit}^  below 
the  middle  of  the  right  clavicle.  Clinical  examination  is 
inconclusive  :  there  is  no  sputum  and  the  physical  signs 
are  ambiguous. 

They  are  generally  considered  to  be  cases  of  chronic 
bronchitis  on  account  of  the  presence  of  rhonchi  and 
rubber  ball  sounds  in  certain  areas,  may  be  the  apex,  the 
axilla,  or  the  mammary  region  ;  but  the  real  diagnosis  is 
evidently  chronic  nodal  pulmonary  tubercle. 

*  Two  months  later  the  patient  died.    No  examination  was  allowed. 


o 


Facing  p.  41. 


Radiography  of  the  Chest  41 


CHAPTER   IV 

Bronchopneumonic  Pseudolobar  Tuberculosis  (Apical) 

Apical  bronchopneumonic  phthisis  may  be  acute,  sub- 
acute, or  chronic.  In  the  very  chronic  forms  the  area  of 
apex  infiltrated  is  generally  small,  and  situated  usually  at 
the  level  of  the  anterior  osseous  extremity  of  the  first  rib. 
Here  a  fibrocaseous  patch  may  be  found,  with  small 
irregular  cavitation  within  it,  or  a  definite  isolated  cavity. 
When  the  disease  spreads  downwards  it  may  heal  from 
above,  and  exhibit  a  slowly  advancing  margin  of  consolida- 
tion in  the  lower  part  of  the  upper,  or  within  the  middle 
lobe.  In  some  cases  the  initial  focus  may  be  in  the 
axillary  region.  , 

In  the  more  acute  apical  and  perihilar  forms,  symptoms 
such  as  cough,  pyrexia,  emaciation,  and  anorexia  are  often 
prominent  before  the  diagnostic  signs  appear.  Such  signs 
as  diminished  or  weak  breath  sounds,  diminished  supra- 
clavicular isthmus,  granular  breathing,  harsh  breathing 
with  prolonged  expiration,  interrupted  breathing,  are  not 
pathognomic,  since  they  may  be  merely  the  persistent 
signs  of  an  arrested  tuberculosis. 

In  the  ordinary  apical  phthisis,  Fowler  localises  the 
initial  lesion  about  two  inches  below  the  right  apex,  and 
nearer  the  posterior  surface  of  the  lung.  Chauvet  places 
this  primary  focus  in  the  middle  of  the  line  joining  the 
intervertebral  space  between  the  seventh  cervical  and  first 
dorsal  with  the  tubercle  of  the  spine  of  the  scapula  (which 
is  generally  quite  easily  seen  and  felt).  This  corresponds 
with  the  radiographic  appearances,  consequently  early 
cases  are  most  profitably  auscultated  and  radiographed  in 
the  supraspinous  fossa  about  the  level  of  the  third  dorsal 
spine.  Before  the  complete  invasion  of  the  upper  lobe  is 
accomplished,  a  second  lesion  may  appear  below  the  apex 
of  the  right  lower  lobe  at  the  level  of  the  fifth  spine,  and 


42  Radiography  of  the  Chest 

about  half  way  between  it  and  the  inner  border  of  the 
shoulder  blade.  It  is  said  that  an  interval  of  quiescence 
may  now  take  place,  after  which  the  lesion  commences  to 
spread  in  two  directions,  (i)  along  the  right  interlobe, 
(2)  towards  the  right  base  ;  and  a  third  lesion  appears  in 
the  upper  lobe  of  the  opposite  lung.  To  follow  the  line  of 
march  radiographically  it  is  necessary  to  take  stereo- 
radiograms  at  frequent  intervals  in  typical  cases ;  and  the 
results  do  not  entirely  coincide  with  those  deduced  from 
percussion  and  stethoscop}^  In  man}'  cases  the  disease 
starts  almost  simultaneously  in  both  apices  ;  in  others  the 
left  apex  only  is  attacked,  and  the  disease  may  then  remain 
for  a  long  time  unilateral  ;  occasionally  it  seems  to  spread 
downwards  on  the  right  (apical),  and  centrifugally  from 
the  hilum  on  the  left  (perihilar).  Furthermore,  when  cavita- 
tion occurs  in  both  acute  and  chronic  cases,  the  line  of  march 
may  be  obscured  by  the  occurrence  of  showers  of  broncho- 
genic foci  affecting  both  lungs,  and  may  subsequently 
advance  more  quickly  in  certain  unexpected  situations. 

1.  Sidne}'  S ,   ast.    16  (4.2.19):    had  an  attack  of 

influenza,  July,  191 8  :  cough  +  :  emaciation  +  :  night 
sweats  +  :  hectic  + .  Clinical  signs :  crepitations  both 
apices,  particularly  on  the  right.  Radiogram,  posterior 
(No.  26) :  bronchopneumonic  pseudolobar  tubercle 
spreading  from  right  apex,  with  cavitation  below  the 
clavicle,  and  a  second  beneath  the  axilla ;  consolidation 
in  the  middle  lobe  :  and  deposition  in  the  right  basal 
lobe  :  on  the  left,  cavitation  commencing  below  sternal 
end  of  left  clavicle,  and  slight  areas  of  infiltration  in  the 
apex  of  the  lower  lobe  of  left  lung  (galloping  phthisis). 

2.  Emma  B ,  aet.  18  (12. 8. 18):  suffered  from  pleu- 
risy, Christmas,  1917.  Clinical :  movement  of  left  chest 
deficient :  no  crepitations  :  winter  cough  :  wasting : 
night  sweats :  anaemia.  Radioscope :  left  diaphragm^ 
inner  half  only  mobile  :  heart  apex  not  adherent :  large 
opacity  in  middle  of  left  field.  Radiogram  No.  27A 
(anterior)  shows  an  advanced  bronchopneumonic  phthisis, 
apparently  commencing  at  right  apex,  where  indurations, 
and  a  number  of  small  cavities  are  visible.     It  has  spread 


u 


J2 

a 


oi 


KacinK  p.  42. 


FacinK  p.  42. 


Radiography  of  the  Chest  45 

throughout  the  right  lung  :  subsequently  it  has  settled 
in  the  left  hilar  area,  thence  spreading  outwards  into  the 
left  lung.  The  latter  is  riddled  with  small  cavities  as 
far  as  the  supraclavicular  apex.  Some  of  the  opacities 
in  the  right  lung  are  very  opaque,  and  probably  cal- 
careous. At  present  the  disease  appears  to  be  quiescent 
(bronchopneumonic  pseudolobar). 

3.  Alice  B ,  aet,  24  (at  least  seven  years  in  duration)^ 

was  in  sanatorium  in  191 2  :  complains  now  of  frequent 
cough  :  expectoration  is  scanty  and  white:  weight  10.10 
in  sanatorium,  now  8.6:  was  diagnosed  in  191 2  double 
apical  phthisis.  Clinical  signs :  crepitations  at  the  left 
apex  and  rhonchi  in  left  upper  lobe  :  no  enlarged  cer- 
vical glands  (Radiogram  No.  27B).  It  is  difficult  now 
to  realise  the  line  of  march  :  there  are  sinuous  small 
excavations  at  right  apex  in  the  second  anterior  inter- 
space :  some  thickened  tubes  in  the  middle  lobe  :  both 
hilar  regions  are  cloudy :  on  left  side  dilatations  of 
tubes:  sinuous  cavitation:  a  pleural  apical  cap,  and  a 
few  small  transparencies  in  the  left  supraclavicular  apex: 
bands  of  indurated  fibrosis  along  the  bronchi :  heart 
central,  some  dilatation  of  the  right  auricle, 

Pcrihilar  Broncliopncnmonic  Pseudolobar  Phthisis 
(Subacute  and  Chronic). 
It  has  been  already  stated  that  perihilar  disease,  whether 
uni-  or  bilateral,  may  be  secondary  to  an  apical  lesion  ;  very 
often,  however,  both  apices,  so  far  as  clinical  and  radio- 
logical examination  can  determine,  are  normal.  Five 
examples  of  this  type  are  now  described  : — 

I.  Amelia  R ,  aet.  35.    Clinical :  in  the  right  upper 

lobe  percussion  note  impaired,  a  few  crepitations.  In 
the  left  upper  lobe  expansion  diminished  :  there  is 
tubular  breathing  above,  becoming  amphoric  near  the 
nipple:  cardiac  apex  not  found.  Radiogram  28:  on  the 
left  side  there  are  many  rounded  opacities  (broncho- 
pneumonic nodal),  connected  by  less  dense  indurations: 
an  irregular  cavitation  extends  as  far  as  the  supra- 
clavicular apex.  On  the  right  side  a  narrow  band  of 
disconnected  induration  from  the  hilum  running  out- 
wards towards  the  axilla,  and  containing  small  cavities. 


44  Radiography  of  the  Chest 

and  dilated  tubes :  the  right  phrenic  leaflet  is  much 
higher  than  the  left.  There  are  a  few  opacities  in  the 
right  middle  lobe.  The  disease  on  the  right  is  older 
and  becoming  arrested.  The  right  extreme  apex  is  free. 
This  patient  contracted  influenza  during  the  winter  of 
1 91 8,  with  a  fatal  result. 

2.  Regina  R ,  aet  16.     Clinical:  has  suffered  from 

cough  for  1 8  months:  expectoration  +  :  tubercle  bacilli 
+  :  right  lung,  percussion  note  impaired  :  crepitations 
right  apex :  harsh  breath  sounds  behind  with  increased 
whisper:  temperature,  g6°-g%°.  Radiogram  2g:  a  uni- 
lateral bronchopneumonic  pseudolobar  infiltration, 
spreading  along  the  right  interlobe  with  irregular  ex- 
cavation (arrows)  above  and  below  it,  near  the  hilum. 
The  lesion  extends  along  the  bronchi  to  the  supracla- 
vicular apex,  where  excavation  also  has  ensued.  The  left 
lung  is  practically  free.  The  heart,  aorta,  and  trachea 
deviated  slightly  towards  the  right. 

3.  James  S ,  a;t.  26  :  family  history  + :  cough  + : 

expectoration  + :  haemoptysis  small,  on  several  occa- 
sions :  night  sweats  — :  97'6°-gg'6° :  Tbc.  after  several 
examinations  — .  PJiysical  signs  :  indefinite  :  a  few  doubt- 
ful crepitations  observed  on  two  occasions  between 
vertebral  border  of  scapula  above  the  spine  and  the 
vertebral  column.  Classed  B,  June,  1917.  Radiogram 
30A  shows  several  round  bronchopneumonic  foci,  nodal, 
outside  the  right  hilum  in  the  interlobar  region,  with 
some  surrounding  induration  and  thickened  tubes  or 
congested  vessels  running  fan-wise  towards  the  axilla. 
Radiological  diagnosis :  right  interlobar  phthisis.  Ten 
months  subsequently  re-examined.  Clinical :  cough  +  : 
Tbc.  now  +:  emaciation  +:  night  sweats  +:  has  had  an 
attack  of  pleurisy  on  right  side.  Radiogram  30B  :  there 
is  now  a  single  perihilar  cavity  (arrows)  in  the  right 
interlobar  region,  which  is  "silent "to  the  stethoscope 
and  communicates  with  several  bronchi:  dilated  tubes  in 
the  middle  lobe  surrounded  by  bands  of  infiltration 
apparently  becoming  fibroid :  diminished  interspaces 
on  the  right,  and  enlargement  of  right  paratracheal 
glands.     A  thin  infiltration  towards  the  right  base. 

4.  Robert  C ,  set   40  (10.9. 17).     Clinical :   patient 

had  an  attack  of  rheumatoid  arthritis  four  years  ago : 


I'aciiiK  p.  44. 


o 


Facing  p.  44- 


Rad.  32  (Ant.)     I\TiliiIar  nodal  tul)ori  lo  in  places  pseuilolobar. 
Kii,'lit  l)asal  piicmnotliorax. 


I'acinR  p.  44. 


Radiography  of  the  Chest  45 

now  complains  of  morning  cough,  with  slight  expectora- 
tion :  a  small  haemoptysis  occurred  for  the  first  time 
four  days  ago  :  a  few  scattered  catarrhal  sounds  in  the 
right  lung,  but  there  are  no  definite  physical  signs. 
Radiogram  31  a,  posterior,  shows  a  band  of  infiltration 
containing  small  cavities  in  the  right  interlobar  area : 
involvement  of  the  middle  lobe  :  lateral  scoliosis,  convex 
to  the  right.  Diagnosis:  right  interlobar  phthisis. 
Second  examination  (12.3. 18).  Clinical:  crepitations  (?) 
both  apices  (crackles),  distant  tubular  breathing  over 
right  middle  lobe :  weight  slightly  increasing.  Radio- 
gram 3 IB.  There  has  been  a  dissemination  from  the 
interlobar  cavities,  which  foci  now  appear  to  be  under- 
going fibroid  metamorphosis.  The  disease  has  now 
become  unilateral  disseminated  fibroid.  The  old  excava- 
tion at  left  apex  is  visible.  The  patient  is  now  following 
his  employment.  Scoliosis  appears  to  be  frequent  in 
these  unilateral  forms. 

5.  Alice  W. ,  aet  20.     Clinical:  anaemic  :  cough  for 

six  weeks  :  expectoration  scanty  :  haemoptysis  —  :  emacia- 
tion (?) :  night  sweats  +  :  dyspnoea  +  .  The  chest  is 
long,  emphysematous  :  crepitations  (?)  at  apex  :  catarrhal 
sounds  behind  :  supraclavicular  isthmus  on  each  side- 
equal  (4)4) '■  Radiogram  32  shows  a  left  perihilar  tuber- 
culosis extending  to  the  summit  of  upper  lobe  :  some 
left  hilar  and  perihilar  excavation:  right  basal  tubercle  r 
two  large  calcareous  opacities  (arrows)  in  right  lung, 
and  a  small  basal  pneumothorax  (arrows).  Partial 
pneumothorax  as  visualised  by  radiology  in  quiet  tubercle 
often  occurs  in  con?icction  tvitli  a  subplcural  calcareous  focus, 
and  it  is  generally  free  from  fluid.  The  condition  in  the 
upper  left  reminds  one  of  the  Laennec's  grey  infiltration, 
which  is  really  a  caseating  lobular  chronic  broncho- 
pneumonia. 

General  Remarks. — The  above  illustrations  show  that 
perihilar  fibrocaseous  tubercle  may  be  almost  exclusively 
unilateral.  If  bilateral  the  pulmonary  lesions  are  not,  as  a 
rule,  cotemporaneous;  one  may  be  subacutely  progressive,, 
whilst  the  other  is  manifestly'  quiescent,  even  retrogressive. 
They  arise  in  connection  with  hilar  or  perihilar  glands  on 
the  same  side,   and   maj'   produce  either  discrete  discon- 


.46  Radiography  of  the  Chest 

nected  nodes  or  broad  homogeneous  infiltrations.  At 
times  the  disease  may  arise  from  apical  lesions — pre- 
sumably, from  their  radiological  aspect,  semi-quiescent — 
in  the  same  or  in  the  opposite  lung,  when  bacilliferous 
material,  issuing  from  a  cavity,  is  scattered  broadcast 
throughout  the  bronchi  and  fastens  upon  the  perihilar  area. 
During  its  subsequent  evolution,  cavities  may  form  in  the 
perihilum,  and  a  second  dispersal  of  aerial  foci  may  pro- 
ceed from  them  which  may  be  partial — affecting  the 
-diseased  side  only — or  it  may  be  general.  In  Radiogram 
30A  the  interlobar  dissemination  is  discrete,  and  probably 
has  spread  by  way  of  the  lymphatic  tracts.  The  evacua- 
tion of  the  deep  perihilar  cavity  (Radiogram  50B)  is  not 
yet  complete  ;  but,  in  this  case,  there  has  been  up  to  the 
present  little  deposition  of  foci  in  adjacent  parts  of  the 
lung. 

The  disease  advances  in  the  upper  lobe  towards  the 
•axilla ;  in  the  lower  lobe  towards  the  costophrenic  sulcus, 
finally,  in  each  case,  producing  a  cuneate  tract  of  infiltra- 
tion with  its  apex  situated  at  the  hilum.  In  the  left  upper 
lobe,  on  account  of  the  absence  of  the  superior  fissure,  the 
opacity  may  be  fan-shaped  (Radiogram  28).  As  the  lesion 
marches  centrifugally  it  becomes  more  and  more  super- 
ficial, until  in  certain  areas  the  characteristic  tuberculous 
jrale  becomes  audible  to  the  stethoscope.  In  the  earlier 
stages,  when  symptoms  form  the  chief  clinical  feature, 
post-tussive  inspiratory  crepitations  may  be  detected  (a) 
€it  the  sides  of  the  chest,  between  the  axillary  lines  above 
the  level  of  the  nipple ;  {b)  in  front,  on  the  left  side  in 
particular,  in  the  parasternal  area  within  the  second  and 
third  interspaces,  or  (c)  behind,  at  the  level  of  the  jiila  or 
a  little  higher,  between  the  vertebral  border  of  the  scapula 
-and  the  spine,  also  {d)  along  the  interlobe  on  the  right, 
or  {e)  at  the  base  of  the  lung.  Mistakes  ma}'  be  made  by 
the  clinician,  who  thinks  only  of  apical  crepitations,  and 
<does  not  auscultate  the  fissures,  the  axilla,  and  the  base. 
When  the  disease  progresses  towards  the  summit,  crepi- 


Radiography  of  the  Chest  47 

tations  (cedema  ?)  are  occasionally  conducted  towards  the 
apex,  before  any  radiological  evidence  is  forthcoming  as  to 
the  existence  of  disease  in  that  area.  Pleuritic  pains  in 
the  axillary  regions,  and  right  basal  effusion,  are  not 
infrequent.  The  latter  is  more  likely  to  occur  when  the 
middle  and  lower  lobes  are  invaded.  Basal  effusions  may 
be  met  with  in  middle  age,  which  recur  several  times  after 
tapping,  and  may  conceal  perihilar  discrete  foci  in  the 
middle  and  lower  lobes.  At  this  period  of  life  they  may 
be  accompanied  by  serious  cardiac  embarrassment  and 
alarming  dyspnoea,  which  necessitate  a  partial  evacuation 
of  the  fluid. 

Perihilar  bronchopneumonic  infiltration,  when  bilateral, 
may  therefore  occupy  the  wings  of  the  chest,  or  it  may 
approach  the  apex  in  the  one,  and  the  base  in  the  other 
lung ;  there  may  be  an  obvious  protrusion  of  the  middle 
intermammary  region  of  the  chest,  especially  in  women, 
and  the  more  marked  the  deformity  the  more  likely  is  the 
disease  to  be  semiquiescent  or  arrested.  Such  disfigurement 
may  be  termed  aymiilar  emphysema.  There  is  a  greater 
tendency  in  this  t3^pe  to  fibrosis  and  chronicity  than  in  the 
purely  apical  variety.  The  prognosis  is  more  serious  in 
the  cavitary  forms,  and,  ccctcris paribus,  the  younger  the  age 
of  the  patient ;  when  the  foci  are  small  and  disconnected, 
the  prospect  is  brighter  than  when  continuous  tracts  of 
infiltration  are  visible  on  the  radiogram.  In  the  strictly 
unilateral  forms  the  outlook  is  also  more  favourable. 
Finally,  this  essentially  chronic  type  appears  to  be  more 
closely  connected  with  the  flat  chest  {thorax  aplati,  or 
paralyticus),  whether  congenital  or  acquired,  which,  when 
it  becomes  emphysematous,  still  remains  practically  flat, 
merely  bulging,  if  at  all,  in  the  lower  middle  and  basal 
parts  of  the  lung. 

Perihilar,  attenuated  or  abortive  tubercle  {phthisis  minor), 
and  perihilar  fibroid  are  mentioned  later  (Chapters  V 
and  VI). 


48  Radiography  of  the  Chest 


CHAPTER  V 

Chronic  Attenuated  or  Minor  Phthisis 

To  the  radiologist  a  heterogeneous  multiplicity  of  forms 
is  included  in  this  category.  The  disease  is  generally 
strictly  localised ;  it  may  become  temporarily  arrested,  or 
may  possess  a  certain  low  activity  which  is  more  or  less- 
continuous.  It  may  remain  quiescent  for  many  years, 
occasionally  altogether;  and  then  approach  the  type 
described  by  Bard  under  the  title  Abortive  Phthisis.  The 
latter  embraces  cases  where  post-mortem  examination 
reveals  a  few  apical  scars  containing  caseous,  calcareous, 
or  fibrous  nodules.  These  nodules  may  also  occur  beneath 
the  pleura  in  other  parts  of  the  lung,  or  within  its  deeper 
regions.  At  other  times  an  area  of  fibro-pneumonic 
infiltration  is  discovered,  in  the  interior  of  which  there 
may  be  several  calcareous  foci,  a  dilated  bronchial  tube,  or 
one  or  more  smooth  cavities.  The  mediastinal  lymphatic 
glands  may  be  enlarged,  and  fibroid  or  calcareous.  The 
physical  signs  are  indefinite ;  there  may  be  an  impaired 
note  at  the  apices,  increased  vocal  vibration,  harsh 
inspiration,  prolonged  expiration,  weak  breath  sounds, 
and  slight  bronchophony,  without  crepitations.  The 
symptoms  are  equally  inconclusive ;  pyrexia  is  absent  or 
trivial,  there  is  an  occasional  dry  cough,  absence  of  bacilli 
in  the  sputum,  and  non-bacillary  haemoptyses  (due  to 
congested  arterioles  ?).  During  the  period  of  haemoptysis 
areas  of  small  crepitant  rales,  and  of  slight  tubular 
breathing,  may  be  perceived  along  the  fissures,  and 
occasionally  concomitant  signs  of  pure  mitral  stenosis, 
chlorosis,  or  thyroidean  hypertrophy,  may  be  present. 
According  to  Piery,  the  so-called  latent  forms,  which  give 
no  clinical  signs,  and  have  no  appreciable  effect  on  the 
organism  at  large,  are  more  or  less  permanently  arrested, 
and   are  often   due   to   affections   involving   the  tracheo- 


< 


U 


< 


Facing  p.  40. 


Radiography  of  the  Chest  49 

bronchial,  bifurcation,  and  hilar  glands,  as  well  as  those 
of  certain  extra-thoracic  regions  (axillary,  cervical,  mesen- 
teric). The  quiescence  may  be  interrupted  by  the 
occurrence  of  a  haemoptysis,  or  of  a  pleurisy  with  or 
without  an  effusion.  These  patients  may  therefore  exhibit 
periods  of  low-grade  activity,  in  which  there  may  be 
slight  evening  pyrexia  and  moderate  night  sweating, 
anaemia,  loss  of  weight,  fatigue,  headache,  and  lassitude. 

The  disadvantage  of  Bard's  classification  lies  in  the  fact 
that  it  was  made  before  the  advent  of  reliable  radiography, 
and,  as  a  consequence,  it  is  to  some  extent  one-sided, 
unsatisfactory,  and  incomplete.  This  authority,  moreover, 
is  apt  to  draw  broad  distinctions  where  radiography 
demonstrates  obvious  connecting  links.  Clinical  examina- 
tion is  notoriously  unable  to  decipher  correctly,  if  at  all, 
events  occurring  far  beneath  the  surface,  whilst  it  is 
practically  mute  with  regard  to  hilar  and  perihilar  lesions. 
In  the  absence  of  actual  post-mortem  investigation,  which 
in  most  of  these  cases  is  obviously  unattainable,  the 
rays  constitute  its  most  reliable  substitute;  experience 
diminishes  year  by  year  the  objections  and  hostile 
criticisms  directed  against  it,  and  at  the  same  time 
emphasises  its  value  and  its  necessity. 

The  radiographical  manifestations  exhibited  by  the  mass 
of  minor  pulmonary  phthisis  may  be  arranged  in 
the  following  manner :  {a)  apical  nodular,  {b)  apical 
infiltrative,  (c)  perihilar  discrete  and  disseminated,  {d) 
perihilar  infiltrative,  {e)  perihilar  fibrotic,  (J)  lymphatic 
disseminated,  and  {g)  bronchitic.  Examples  of  each  will 
now  be  described. 

As  a  genera]  rule  these  cases  are  closed,  that  is,  the 
sputum,  if  obtainable,  is  devoid  of  bacilli.  The  symptoms 
are  slight,  and,  except  at  certain  times,  may  cause  little  or 
no  anxiety — malaise,  slight  loss  of  weight,  tachycardia, 
occasional  niglit  sweats.  There  may  be  a  few  indefinite 
crepitations  either  at  one  apex,  within  the  axillary  lines, 
along  the  interlobes,  or  at  the  base. 

B 


50  Radiography  of  the  Chest 

(a)  Apical  nodular.    George  F ,  aet.  45  (8. 5. 19)  :  dull 

to  percussion  at  right  base  :  weak  breath  sounds  :  TF — : 
VR  — :  Diagnosis:  thickened  pleura  +  phthisis  of  the 
right  lung :  had  influenza  with  pneumonia  in  December, 
191 8:  cough  since:  does  not  improve:  invalided  from 
Army,  March,  191 9,  with  the  diagnosis  of  chronic 
bronchitis  and  emphysema.  Radiogram  33,  nodular 
tubercle,  affecting  right  apex  especially  :  excavation  right 
supraclavicular  apex  near  axilla  :  calcareous  opacities, 
one  large  opacity  at  the  level  of  left  clavicle  near  sternum: 
dilated  tubes  left  upper  lobes  :  emphysema  both  lungs  : 
slight  hypertrophy  of  left  ventricle.  A  chronic  case, 
reactivated  probably  by  influenzal  attack. 

{b)  Apical  infiltrative.     Elizabeth  L ,  aet.  38(3.3.17): 

was  in  hospital  for  gastric  ulcer  in  1916:  suffered  from 
an  attack  of  pleurisy  two  months  ago  with  cough  and 
haemoptysis  (^IV)  at  commencement.  Right  apex, 
percussion  note  impaired,  air  entry  at  both  apices  poor,  a 
few  crepitations  at  the  left  apex  :  Tbc  — .  Radioscope  : 
diaphragmatic  movements  good:  both  supraclavicular 
apices  open  on  cough  :  pulmonary  transparency  generally 
impaired.  Radiogram  34,  posterior,  an  area  of  infiltration 
at  left  apex,  containing  small  cavities  :  in  right  axilla  an 
opacity  suggesting  a  fibroid  patch,  to  which  a  thickened 
bronchus  runs  :  a  few  scattered  old  foci  in  right  lung: 
emphysema  in  right  base  :  interspaces  diminished  above 
on  right  side  :  mediastinum  slightly  deflected  towards  left: 
slight  scoliosis,  convex  to  right.  (In  scoliosis  the  inter- 
spaces on  concave  side  are  narrower.)  Evidently  an  old 
no  n-progressive  case.(A  very  co  mmon  type  of  minor 
phthisis,  but  generally  the  right  apex  is  involved  instead 
of  left.) 

3.  Emma  R ,  aet.  39 :  had  pleurisy  on  left  side  two 

months  ago  with  pain  :  cough  +  :  yellow  expectoration  : 
no  haemoptysis  :  general  weakness.  Clinical :  moist 
sounds,  emphysema :  diagnosis,  chronic  bronchitis. 
Radiogram,  posterior,  35  :  below  apex  of  right  axilla,  an 
area  of  induration,  a  few  cavities  with  disseminated  foci 
within  right  upper  lobe,  especially  between  axilla  and 
hilum  :  emphysema  :  median  heart,  cardioptosis. 

4.  Ellen  M ,  aet.  25   (5.3.19):  influenza  pneumonia 

last    November  :  cough  —  :    expectoration  —  :    haemop- 


H 


l-'acing  p.  50. 


c< 


Facing  p.  50. 


Radiography  of  the  Chest  51 

tysis —  :  emaciation  —  :  dyspnoea  +  :  pain  occasionally 
on  left  side.  Right  apex  a  few  moist  sounds,  and 
percussion  note  impaired :  t°  irregular,  97°-99°  : 
Radiogram  2,6  :  slight  deviation  of  mediastinum  to  left : 
patch  of  infiltration  in  right  axilla  with  a  few  small 
cavities:  thickened  tubes  and  bands  of  cirrhosis  in  both 
fields,  especially  at  the  right  base  and  in  the  middle 
lobe.  Many  sanatorium  cases  exhibit  a  similar  appear- 
ance. Occasionally  the  infiltration  is  in  the  left  upper 
lobe  instead  of  the  right. 

Perihilar  discrete. — Annie  C (19. 3. 18),  aet.  24:  an 

in-patient  six  years  ago  :  remained  well  till  January, 
when  she  began  to  be  hoarse  (paralysis  of  left  cord): 
glands  of  neck  on  left  side  enlarged,  but  not  caseating  : 
doubtful  signs  at  both  apices  :  mitral  stenosis.  Radiogram 
37  :  enlarged  left  auricle  (mitral  stenosis)  :  old  caseating 
nodal  foci  (some  calcareous)  in  both  lungs,  especially 
right  middle  lobe  :  left  paratracheal  glands  not  obviously 
enlarged  :  paralysis  of  cord  probably  due  to  enlarged  left 
auricle  compressing  the  recurrent  nerve  against  aorta 
(case  of  minor  tubercle  associated  with  mitral  stenosis). 

Nellie  K ,  aet.  32  :  husband  suffers  from  pulmonary 

phthisis,  he  has  been  in  a  sanatorium  and  is  now  at  home. 
She  has  complained  of  pain  in  the  chest  for  five  months  : 
cough  +  :  expectoration  slight  :  haemoptysis  four  months 
ago  :  wasting  +  :  night  sweats  — :  Tbc.  — .  Clinical  signs  : 
impaired  resonance  left  apex,  no  adventitious  sounds. 
Radiogram  38  :  thorax  pareticus,  increased  area  of  both 
hilar  opacities  :  disseminated  foci  chiefiy  in  lower  and 
basal  fields  of  lung  :  slight  general  cylindrical  dilatation 
of  bronchi  :  small  excavations  (?)  in  both  supraclavicular 
apices,  from  which  possibly  showers  of  bacilli  may  have 
escaped  with  the  ha;mopt3'sis  four  months  ago:  disease 
now  becoming  quiescent.  Patient  seen  a  year  later, 
practically  in  statu  quo. 

In  thejlat  or  paralytic  thorax  {vide  Diag.  6)  the  antero- 
posterior diameter  of  the  chest  is  reduced;  the  upper 
anterior  interspaces  appear  broader  in  front  than  usual  ; 
the  lower  ribs  are  deep,  crowded,  the  lowest  approximating 
the  iliac  crest.  There  are  often  deep  clavicular  grooves 
and  wasted  pectoral  muscles.     The  descent  of  the  clavicle 


52 


Radiography  of  the  Chest 


brings  the  aortic  bulge  nearer  to  it.  In  many  instances 
it  is  a  secondary  manifestation,  the  outward  sign  of  an 
arrested  tuberculous  infection,  in  individuals  with  feeble 
inspiratory  energy  and  of  an  acquired  immunisation. 
Should  tubercle  become  active  again  in  adult  life,  it  is 
generally  of  a  slow  evolutionary  type,  liable  to  become 
chronic,  or  entirely  latent. 

Diagram  6. 


Maud  W- 


October,  191 8 


,  set.  20  (18. 3. 19):  cough  since  "flu' 
pain  on  left  side:  wasting +:  sweats 


m 


97*2' 


Tbc  +  :    nasal  obstruction:    percussion  note 


diminished  on  left :  crepitations  at  bases  behind  :  m- 
creased  whisper  both  apices,  vocal  cords  slightly  injected. 
Radiogram  39 :  disseminated  nodular  phthisis  affecting 
middle  lobe  chiefly,  and  base  of  right  upper  lobe  :  the 
condition  at  right  hilum  suggests  an  irruption  into  the 


< 


Facing  p.  52. 


— 

■^ 

'J 

M 

'C 

^ 

o 

Lh 

o 

f3 

■^ 

3 

u.'^ 


Facing  p.  52. 


Radiography  of  the  Chest  53 

bronchi  from  caseating  glands :  in  left  hilum  discrete 
nodules,  with  some  dilatation  of  tubes  running  to  left 
apex :  both  supraclavicular  apices  clear :  slight  paretic 
thorax  and  basal  emphysema,  with  some  left  axillary 
pleuritic  adhesion, 

Albert  W ,  aet.   29  (28.5.18):  was   in   sanatorium 

six  years  ago  :  rejected  by  the  military  tribunal  one  year 
ago:  cough  ver}' little:  sputum  of  a  morning  :  haemoptysis 
six  years  ago,  streaks  :  no  emaciation.  Clinical  signs  : 
right  chest  flat :  percussion  note  impaired :  vocal 
resonance  + :  no  definite  physical  signs  :  heart  deviated 
to  right  :  bases  clear :  Radiogram  40 :  on  the  right  side 
fibroid  interlacing  strands  up  to  the  first  rib  :  a  fibroid 
mass  in  right  hilum,  thickened  strands  and  dilated  tubes 
running  to  right  base  :  on  left  side  slightly  increased 
densit}^  of  the  hilum,  small  nodules  in  the  external  parts 
of  lung,  and  particularly  towards  and  including  the  left 
base  (mottling).  Cardiac  outlines  somewhat  increased, 
aortic  arch  apparently  transposed  to  the  right.  A  case 
which  will  show  periodic  bursts-  of  minor  activity. 

Elizabeth  M ,  aet.  8,  always  delicate  :  bronchitis  for 

18  months  :  now  cough  and  pain  in  left  side  for  six 
months :  t°  99°,  evening :  expectoration  scanty : 
bacilli  +:  night  sweats  —  :  clubbing  — :  family  history — . 
Clinical:  heart  apex  beat  normal:  right  chest  flat,  de- 
ficient movement :  dulness  to  percussion  :  crepitations  : 
posteriori}''  also  crepitations  in  both  lungs,  and  dulness 
below  angle  of  scapula:  cavity  (?)  right  axilla  behind. 
Clinical  diagnosis :  hilar  phthisis,  rather  advanced. 
Radiogram  41  :  both  hilar  opacities  increased  :  trachea 
deviated  to  right,  rather  more  than  normal :  an  opacity 
outside  it  on  right,  which  may  be  an  enlarged  tracheo- 
bronchial opacity  :  irregular  cavitation  right  axilla : 
small  foci  along  bronchi  running  from  right  apex  to 
right  hilum,  and  along  the  bronchi  passing  to  the  right 
base:  right  phrenic  adhesion  (phenomdne  du  feston 
diaphragmatique-Maingot). 

Pcrihilar  and  hilar  infdlration. — Ilenr}-  L (20.6. 18), 

act,  6  :  pallor  :  dyspnoea  :  tubular  breathing  right  base, 
also  some  at  left  base  (conducted?),  and  crepitations 
with  dulness  to  percussion.  22,7,18,  dulness  at  right 
base,    no    crepitations    now :     no    tubular     breathing. 


54  Radiography  of  the  Chest 

Radiogram  42  :  a  triangular  opacity  (infiltration)  with 
base  at  right  hilum  and  apex  near  axillary  bend  of  the 
fifth  rib  (therefore  in  middle  lobe  with  its  superior  edge 
limited  by  small  interlobar  fissure) :  caseating  (?)  tracheo- 
bronchial opacity  on  the  right :  some  nodules  along 
bronchi  running  to  right  apex  and  a  few  in  left  hilum  : 
Tbc.  — :  re-examined  six  months  later :  appearances 
practically  in  statu  quo. 

Annie  M (3.4.19),  aet.  31  :  suffers  from  bronchitis 

every  winter:  influenza,  December,  1918  :  percussion 
note  impaired  right  lung :  rhonchi  over  left  lung : 
crepitations  left  upper  lobe.  Radioscope  :  right  diaphragm 
immobile,  left  sluggish  :  cuneate  interlobar  shadow. 
Radiogratn  43  :  a  cuneate  infiltration  with  its  apex 
external,  starting  from  the  right  hilum  :  fibrosis  of  middle 
lobe  :  thickening  of  bronchi  in  right  upper  lobe,  and 
some  fibrous  nodules  in  left  hilum. 

Occasionally  a  similar  hilar  infiltration  is  found  at  the 
base  of  the  right  upper  lobe,  the  lower  margin  of  which 
runs  along  the  interlobe.  The  real  significance  of  opacities 
of  this  kind,  and  in  this  region,  is  not  clear.  They  may  be 
due  to  a  direct  tuberculous  infection  of  the  lung  by  way 
of  caseating  hilar  or  bifurcation  glands.  If  radiographed 
again  at  the  interval  of  some  weeks  the  opacity  may  be 
found  to  have  disappeared,  leaving  behind  merely  an  inter- 
lobar stripe  ;  moreover,  the  opacity  may  reform  (recurrent 
hilar  infiltration).  It  has  been  suggested  that  these  relapses 
may  be  due  to  the  evanescent  appearance  of  recurrent 
interlobar  effusions.  In  the  case  of  the  boy  mentioned 
above  {Radiogram  42)  it  is  possible  that  the  opacity  was 
originally  bronchopneumonic,  and  has  now,  six  months 
afterwards,  become  fibrotic.  In  other  words,  these  opacities 
are  not  always  of  a  tuberculous  nature,  and  the  diagnosis 
from  bronchopneumonia  must  depend  on  subsequent 
radiological  examination,  assisted  by  clinical  and  labora- 
tory methods  of  investigation. 

Lily    M (i  1.3. 19),    aet.    19:    a   mouth  breather: 

nutrition  good  :  influenza  and  pneumonia,  October,  191 8: 
cough  +  :  expectoration  slight :  haemoptysis  in  October. 


C  s! 


Facing  p.  54. 


Radiography  of  the  Chest  55 

Clinical  signs :  percussion  note  impaired  with  crepitations 
at  both  apices :  Radiogram,  posterior,  No,  44  :  both  hilar 
opacities  prominent,  especially  the  right :  two  small 
infiltrations  outside  left  hilum  (arrows) :  network  of 
thickened  lymphatics  (?)  running  to  left  apex :  foci  in 
the  left  first  posterior  interspace,  scarcely  visible  except 
on  plate  :  thickened  bronchi  or  vessels  in  right  lung  : 
apparently  an  infiltration  at  the  level  of  the  sternal 
osseous  extremity  of  first  right  rib  :  superior  emphysema, 
some  homogeneous  shadowing  in  the  basal  and  axillary 
areas  on  right  side  :  a  few  foci  brought  into  view  through 
the  sternal  end  of  right  clavicle. 

Examples  of  perihilar  fibrosis  are  described  in  Chapter 
VI.  Two  cases  are  here  inserted  of  the  disseminated  type, 
one  chiefly  affecting  the  right  middle  lobe,  the  other  both 
hila  and  their  prolongations. 

Ada  F ,  aet.  23:  (T.B.  Dispensary):  cough  nearly 

gone:  sputum  scanty  :  haemoptysis — :  night  sweats?: 
emaciation  ? :  liable  to  catarrh  :  slight  exophthalmos : 
patient  looks  well  and  is  not  thin.  Ph3'sical  signs  nil : 
Radiogram  45,  shows  a  disseminated  old  disease, 
probably  spreading  from  hilum,  and  producing  some 
fibrosis  of  the  right  middle  lobe :  a  few  old  fibroid 
specks  in  the  lower  part  of  right  upper  lobe :  apices 
clear,  excepting  an  apical  pleural  cap  on  left.  The 
case  may  be  entered  among  the  latent  forms — with 
regard  to  tubercle  it  is  now  practically  quiescent. 
Generalised  obsolete  and  fibroid  disseminated  lesions 
of  this  type  frequently  accompany  exophthalmic  goitre. 

Nettie  L ,  ajt.  22  :  has  had  a  cough  for  two  years : 

haemoptysis  eight  months  ago,  small:  clubbing:  cough 
tight:  vomits  with  cough:  appetite  poor:  air  entry  into 
both  lungs  poor:  at  right  base  breath  sounds  practically 
absent :  wheezy  rales  over  both  lungs :  dulness  to 
percussion  over  left.  Clinical  diagnosis :  bronchitis. 
Radiogram 46:  chest  flat  and  paretic:  basal  emphysema: 
both  hila  fibrotic,  prolonged  upwards  and  downwards  : 
bronchus  running  to  upper  left  lobe  dilated,  and  thick- 
ened :  small  nodules  along  bronchi :  slight  dissemination 
in  the  wings  of  chest :  heart  cardioptosis,  with  hypoplasia 
(narrow,  long),  aorta  narrow  :  no  infiltrations.    Perihilar 


56  Radiography  of  the  Chest 

fibroid  disease  in  which  the  signs  of  past  tubercle  are 
fast  disappearing. 

Lymphatic  dissemination. — Maud  S ,  aet.  33  :  suf- 
fered from  severe  attack  of  pertussis  over  one  year  ago, 
during  which  she  had  an  attack  of  haemoptysis :  never 
well  since :  cough  morning :  expectoration  small  in 
amount  and  dark  :  palpitation  :  giddiness.  Clinical  signs  : 
chest  flat :  weak  breathing  left  upper  lobe :  slight 
systolic  murmur :  t°  normal.  Radiogram  47 :  linear 
opacities,  thickened  lymph  trunks  following  the  course 
of  the  bronchial  tree  :  tubes  cylindrically  dilated  in  left 
upper  lobe  and  at  bases  :  dilated  tubes  in  right  middle 
lobe :  commencing  calcification  of  rib  cartilages  on  both 
sides :  diminished  transparency  in  right  upper  lobe  : 
right  hilar  shadow  intense :  enlargement  of  lymphatic 
nodes  (at  bifurcation  of  bronchi)  nearly  to  the  periphery : 
pleuritic  thickening  left  apex. 

Rosina   W ,   aet.  51  :  cough   on  and  off  since  an 

attack  of  pleurisy  two  years  ago :  no  expectoration : 
influenza  nine  months  since  :  a  few  crepitations  at  right 
apex  which  disappear  on  cough  (pleuritic) :  rough  breath 
sounds  on  right :  crepitation  and  friction  sounds  at  the 
right  base :  dulness  to  percussion  above  left  diaphragm. 
Radioscope :  diaphragmatic  movements  impaired  :  scle- 
rosis of  aorta  :  some  diminished  transparency  in  the  right 
lung.  Radiogram  48 :  perihilar  disseminated  tubercle 
(peribronchial):  dilatation  of  tubes  generally  with 
thickened  walls,  especially  in  the  left  upper  lobe :  and 
in  certain  localities,  as  in  left  mammary  region,  studded 
with  small  nodules.  Opacities  due  to  nipples  conspicuous 
(arrows),  both  hilar  opacities  intense,  and  paravertebral 
bronchus  in  right  upper  lobe  much  thickened  :  several 
dense  opacities  in  right  hilum  (anthracotic).  Thorax 
paralyticus. 

Bronchitic{l).  Mar3^J.B (5.3.18),  ast.  19:  injanuarj^ 

191 7,  had  an  attack  of  influenza  with  pleurisy,  each  side 
in  succession  :  in  March  the  abdomen  became  distended, 
but  subsided  after  a  few  months'  treatment :  cough  —  : 
expectoration  — :  bacilli — after  many  examinations: 
emaciation  +  :  night  sweats  +  :  a  few  crepitations 
occasional!}'-  audible  in  the  right  upper  lobe  with  inter- 
rupted sounds.     Radiogram  {anterior)  49  shows  dilated 


Facing  p.  56, 


Rad.  49  (AnL)— Chronic  fibrocaseating  broiichitic  (?)  phthisis. 


Facing  p.  50. 


Radiography  of  the  Chest  57 

and  thickened  bronchi  throughout :  dense  right  hilar 
opacities  reaching  nearly  to  the  base :  the  bronchi  and 
ramifications  exceedingly  well  seen  in  certain  localities, 
suggesting  a  perihilar  caseating  bronchitis  :  *  resembling, 
in  the  right  upper  lobe,  the  stunted  branches  of  a 
leafless  tree  (upper  arrow) :  a  small  infiltration  left 
axilla:   emphysema  both  lungs.     {Vide  Chapter  IX.) 

*  Or  a  slowly  advancing  tuberculous  lymphangitis. 

Additional    remarks    concerning    the    relations    between    tubercle    and 
certain  types  of  bronchitis  will  be  found  in  Vol.  II. 


58  Radiography  of  the  Chest 


CHAPTER    VI 

Pulmonary    Fibroid   Tuberculosis 
{Phthisis   Fibrosa) 

The  designation  "  fibroid  pulmonary  tubercle "  may  be 
reserved  for  those  cases  in  which  the  radiogram  shows 
numerous  fibroid  deposits,  extensive  areas  of  fibrosis,  or 
evidence  of  considerable  displacement  of  internal  organs, 
and  deformities  of  the  chest  wall  with  or  without  the 
presence  of  cavities.  In  many  cases  the  continuous 
shrinking  of  the  fibrous  tissue  is  carried  to  an  extreme, 
and  leads  to  massive  distortion  of  the  chest  wall,  intense 
crowding  of  the  ribs,  marked  deviation  of  the  mediastinum, 
and  blurring  of  the  aortic  arch  and  cardiac  outlines.  The 
degree  of  disfigurement  of  the  chest  depends  on  the 
unilaterality  of  the  disease,  on  the  age  of  the  individual, 
and  on  the  iproduction  of  thickened  parietal  adhesions  of 
the  pleural  wall.  The  aifection  is  often  limited  chiefly  to 
one  lung,  the  other  becoming  hypertrophied  and  passing 
beneath  the  sternum  and  in  front  of  the  spine  into  the 
diseased  side.  In  these  unilateral  cases  of  pulmonary 
cirrhosis,  whether  tuberculous  or  purely  fibroid,  B^clere 
has  called  attention  to  the  displacement  of  the  mediastinum^ 
which  occurs  during  deep  inspiration^  towards  the  diseased 
side. 

The  varieties  of  fibroid  tubercle  may  be  provisionally 
grouped  in  the  following  manner : — 

1.  Fibroid  disseminated  nodular  and  nodal  (P.  fibro- 

disseminata). 

2.  Fibroid  infiltrative — pseudolobar  and  lobar,  often 

containing  small  cavities  and  dilated  tubes  (P. 
fibro-densa). 

3.  Fibroid   peribronchitic,    in    which    the    bands    of 

cirrhosis  appear  either   as  linear,  often  wavy 


Radiography  of  the  Chest  59 

opacities,  or  as  shorter  fusiform  shadows  along 
the  course  of  the  bronchi. 

4.  Fibroid    diffuse    granular,    with    a    ground-glass 

appearance   on  the   radiogram — chronic   inter- 
stitial tubercle  (P.  fibro-diffusa). 

5.  Fibroid    cavitary    forms  par   excellence   (P.    fibro- 

cavernosa). 

Of  these  types  the  nodular  and  nodal  forms  may  become 
arrested  for  years.  The  ground-glass  forms,  which  are 
uncommon,  may  be  diagnosed  chronic  interstitial  pneu- 
monia by  the  clinician.  These  are  practically  permanently 
arrested ;  also  the  peribronchitic  forms  may  settle  down 
and  become  quiescent ;  in  the  cavitary  forms,  when  the 
excavation  is  complete,  the  prognosis  becomes  more 
hopeful.  The  ultimate  outcome  is  more  dependent  on 
secondary  conditions,  such  as  the  incidence  of  sclerosis  in 
the  systemic  vessels  and  viscera,  the  age  of  the  patient, 
and  the  nature  of  his  environment.  In  middle  life,  and 
beyond  it,  many  of  these  cases  masquerade  as  chronic 
bronchitis  and  asthma ;  the  tuberculous  character  of  the 
disease  may  only  be  verified  by  the  presence  of  the 
so-called  tuberculosis  granules  in  the  sputum,  and  its 
tuberculogenic  power  after  inoculation  into  the  lower 
mammals,  as  the  guinea  pig.  Some  more  easil}^  applied 
pathological  test  is  an  urgent  desideratum.  If  incident 
at  an  early  age  the  displacement  of  the  mediastinal 
organs  may  become  extreme ;  nevertheless,  life  may  be 
prolonged,  even  under  these  conditions  of  severe  cardio- 
vascular strain,  for  several  years  {vide  Radiograms  63A 
and  b). 

I.  Phthisis  jxhro-disseminata  is  generally  bilateral,  and 
often  appears  to  be  the  direct  result  of  fibrosis  following 
subacute  types  of  the  same  name  (Chap.  III).  When  it  is 
bilateral,  it  is  usually  accompanied  by  double  emphysema, 
which  throws  into  bold  relief  the  opaque  foci  when  viewed 
on  the  fluoroscopic  screen.  The  picture  becomes  even 
more  striking  after  an  attack  of  asthma,  a  complication 


6o  Radiography  of  the  Chest 

which  is   frequent  in  these  individuals  as  they  advance 
in  years. 

(a)  Archibald  E ,  aet.  28  (26.2.18).     Clinical:  has 

been  in  the  army  since  boyhood :  cough  +:  emaciation  +: 
night  sweats  —  :  heart  apex  beat  normal :  flattening  and 
diminished  movement  right  apex :  crepitations  both 
apices.  Radiogram  50 :  disseminated  fibroid  tubercle 
with  cylindrical  dilatation  of  tubes  throughout :  some 
cavitation  at  right  apex  :  small  bronchopneumonic  nodes 
and  thickened  bronchi  :  several  patches  of  consolidation 
below  the  left  axilla,  and  some  excavation  in  the  lowest 
(arrow)  Radiological  diagnosis :  fibroid  disseminated 
tubercle. 

Those  cases  in  which  the  nodules  become  fibro- 
calcareous  may  be  included  in  this  category.  They  are 
often  accompanied  by  calcareous  metamorphosis  of  the 
lymphatic  glands  in  the  neck,  in  the  axilla,  and  of  the 
glands  along  the  internal  mammarj''  artery.  In  the 
unilateral  forms  the  diseased  lung  may  be  prevented 
from  becoming  emphysematous  by  the  presence  of 
thickened  and  adherent  pleura  at  the  base.  In  such 
cases  the  comparatively  healthy  lung  hypertrophies  and 
finally  becomes  emphysematous. 

2.  Fibroid  infdtrative  disease  leads  to  the  formation  ot 
large  opaque  areas,  as  seen  on  the  screen.  These  may  be 
present  in  one  or  both  upper  lobes  covering  the  supra-  and 
immediate  infra-clavicular  regions  with  a  dense  veil,  or 
they  may  be  present  in  other  parts  of  the  field,  as  the  base 
of  the  right  upper  or  in  the  middle  lobe.  Tvro  cases  are 
described  in  Chapter  VII. 

(^b)  Henry  W ,  aet.  16(11.9.16).     Clinical:  family 

history  —  :  bronchitis  as  a  child  :  cough  now  six  weeks  : 
expectoration  slight :  Tbc.  +  :  haemoptysis  —  :  night 
sweats  —  :  movement  of  apices  fair  (?) :  percussion  note 
impaired,  crepitations  and  breath  sounds  harsh  at  both 
apices :  pyrexia  irregular:  temperature  normal  on  leaving 
for  sanatorium  (21.5. 17).  Radiogram  51:  dense  in- 
filtrations at  both  apices,  with  lighter  areas,  on  the  plate 
at  the  level  of  the  osseous  end  of  the  first  right  rib : 


»i 


oi 


Oh 


« 


Facing  p.  60. 


Radiography  of  the  Chest  6i 

disease  more  advanced  in  left  upper  lobe  :  long  cirrhotic 
streamers  running  downwards  along  the  bronchi  : 
trachea  deviated  to  right :  some  dilatation  of  bronchi  at 
the  right  hilum,  and  small  disseminated  nodules  in  the 
rest  of  the  right  lung.     Heart  median,  and  narrow. 

(r)  Mrs.  K ,  aet.  23.     Clinical:  in   left  upper  lobe, 

dulness  to  percussion,  bronchial  breathing,  moist  sounds : 
sputum,  Tbc.  —  .  Clinical  diagnosis :  pulmonary  tuber- 
culosis in  left  lung.  Radiogram  52  :  both  hilar  opacities 
increased  in  density  and  fibrotic  :  scattered  nodules 
throughout  the  right  lung:  a  triangular  area  of  fibrosis 
extending  from  the  left  hilum  towards  the  axilla  with  its 
apex  external,  and  containing  a  few  transparencies 
(cavities  ?).     Diagnosis,  left  perihilar  fibroid. 

3.  In  the  peribronchial  fibroid  type  (peribronchitis  fibrosa) 
the  fibrosis  often  assumes  the  form  of  wavy  bands  of 
opacity,  which  sometimes  form  thick  sheaths  around  the 
bronchi.  They  may,  originally,  be  partial  disseminated 
nodular  ;  in  other  instances  they  may  be  due  to  gradual 
spread  along  the  peribronchial  lymphatics  from  the  hilum  ; 
occasionally  they  are  the  final  residues  of  arrested 
bronchopneumonic  tubercle  in  which  the  lesion  has 
advanced  per  contiguitatem  along  the  bronchial  wall. 

{d)  Jane  F ,  aet.   42  :  examined  as  a  contact  case  : 

has  been  nursing  a  daughter  who  died  of  pulmonary 
phthisis.  Clinical:  there  are  some  distant  sounds  at 
both  roots,  especially  the  left,  a  faint  cardiac  systolic 
murmur  not  conducted  outwards  :  oedema  of  the  legs  at 
night.  Clinical  diagnosis  as  regards  tubercle  negative. 
Radiogram  53  :  old  cavitary  infiltrations  at  both  apices, 
with  fibroid  nodes  and  bands  running  towards  the  hila. 
Both  hilar  opacities  dense.  Dilatation  of  ascending 
aorta  and  slight  cardiophrenic  adhesion  at  the  apex. 

Such  cases  emphasise  the  advisability  of  the  examina- 
tion of  contact  individuals.  Parents  suffering  from  quasi- 
arrested  old  disease  may  infect  their  children  and  outlive 
them. 

{e)  Florence   E ,  aet.    35.      Clinical:    caught   cold 

16  months  ago:  never  well  since:  complains  of  pre- 
cordial pain  radiating  down    left   arm   after   exertion : 


62  Radiography  of  the  Chest 

children  seven — four  dead  :  some  had  snuffles.  Previous 
history,  bronchial  catarrh.  Physical  signs,  left  upper  lobe 
dull  to  percussion,  crepitations  in  front  and  behind  left 
apex,  and  physical  signs  of  a  cavity :  Tbc.  —  :  dyspnoea 
+  +.  Clinical  diagnosis,  fibroid  tubercle  (?),  media- 
stinitis  (?).  Radiogram  54  :  in  the  left  upper  lobe  a 
condition  of  fibrosis  with  small  cavities :  below  these 
again,  dilated  tubes :  scattered  patches  in  the  right 
lung :  right  phrenic  leaflet  irregular.  X-ray  diagnosis, 
pulmonary  fibrosis  of  left  upper  lobe  with  bronchiectasis  : 
possibly  gummatous  and  non-tuberculous.  Wassermann 
not  employed. 

(/)  Edward   P ,  aet.   28  (4.4.17).     Tea  salesman: 

invalided  from  Army,  191 5  :  haemoptysis,  two  ounces  on 
three  occasions  ten  years  ago  :  cough  slight :  expect- 
oration small  in  amount,  yellow :  Tbc.  +  :  emaciation, 
one  stone :  dorsal  kyphosis :  right  lung  bronchial 
breathing  and  rhonchi  locally  :  fine  crepitations  on  deep 
inspiration  at  both  apices  above  clavicles  :  dulness  to 
percussion  :  crepitations  cleared  up  after  a  few  weeks. 
Climcal  diagnosis:  pulmonary  tubercle  of  both  apices. 
Radioscope,  both  diaphragmatic  halves  move  well :  apices 
dull,  not  opening  on  cough  :  heart  median,  long,  narrow. 
Radiogram  55,  fibroid  nodules  and  fusiform  bands  of 
fibrosis  in  both  apices  :  small  supraclavicular  excava- 
tions (?) :  disease  spreading  downwards  internally  and 
along  axilla  on  right,  more  centrally  on  left  side  :  a  dense 
fibrotic  opacity  between  left  aortic  bulge  and  apex  of 
left  lung  ;  basal  emphysema. 

(4).  Diffuse  granular  forms  (P.  fibro-diffusa).  This 
type  of  fibroid  disease  of  the  lung  may  be  overlooked  by 
the  radiologist,  especially  when  it  presents  no  isolated 
opacities,  but  is  uniformly  grey.  It  may  be  erroneously 
considered  to  be  a  thin  diffuse  pleuritic  th/ckening. 
Careful  examination  of  a  good  plate,  however,  may  reveal 
the  signs  of  an  old  apical  or  perihilar  excavation  surrounded 
by  an  opaque  infiltration,  or  dilated  perihilar  tubes 
encircled  by  what  appear  to  be  caseous  shadows.  It  is 
often  diagnosed  as  chronic  interstitial  pneumonia,  espe- 
cially if  the  clinical  history   is  suggestive,  and  the   past 


i 


Facing  p.  62. 


a 


X 


a 
■5 


u 


ta  ^ 


racing  p.  62. 


Radiography  of  the  Chest  63 

evidence  of  a  tuberculous  origin   is   ambiguous,   uncon- 
sidered, or  ignored. 

(g)    Bessie   C ,    aet.   29   (3.10. 18).      Wasting  +  : 

appetite  poor :  has  had  pneumonia  several  times. 
Clinical  signs :  dulness  at  left  base,  heart  slightly  de- 
viated to  the  left.  Clinical  diagnosis :  fibrosis  of  the  left 
base.  Radioscope,  deviation  of  heart  and  mediastinum 
to  the  left  :  adhesion  of  left  phrenic  leaflet  to  the  costal 
wall  externally :  outer  half  immobile.  Radiogram  56 
(anterior),  apex  of  heart  to  the  left :  near  left  hilum  at 
level  of  sixth  rib  two  small  opacities  surrounding  a 
dilated  bronchus.  Both  lungs  are  emphysematous,  and 
the  abrupt  twist  of  the  ribs  on  the  left  side  just  above 
the  diaphragm  indicates  old  pleuritic  adhesion. 

Some  of  these  cases  are  evidently  arrested  chronic 
tubercle,  since  an  apical  cavitation  is  present.  In  the 
posterior  radiogram  of  this  case  there  were  a  few  small 
excavations  at  the  left  apex.  Others  are  of  perihilar  origin, 
and  the  signs  of  tuberculosis  are  obscured  by  the  homo- 
geneous fibrosis,  and  become  revealed  only  after  the 
employment  of  laboratory  methods.  The  next  radiogram 
shows  a  transitional  condition. 

(h)  Katherine  W ,  aet.   34.     Has  suffered  from  a 

winter  cough  for  years :  expectoration  —  :  haemop- 
tysis —  :  Tbc.  —  :  breath  sounds  clear:  crepitations 
outside  cardiac  apex  in  front  and  over  the  left  lung 
behind,  with  dulness  to  percussion.  Radiogram  57 
(anterior),  heart  slightly  pulled  over  towards  the  left : 
metal  square  on  left  nipple  :  a  lateral  axillary  pleuritic 
thickening  over  left  lung,  ending  abruptly  just  below 
the  nipple:  acute  bending  of  the  ribs  on  left  side:  in 
the  right  lung  a  granular  appearance,  showing  a  studding 
of  foci  along  the  thickened  bronchial  tubes  :  en  larged 
right  hilum,  and  an  unevenly  contracted  right  phrenic 
leaflet.  The  crepitations  were  evidently  of  pleuritic 
origin. 

Chronic  interstitial  tuberculosis  may  occur  in  associa- 
tion with  pure  mitral  stenosis. 

(i)     Rosa    M ,    aet.     35.       Cough     nocturnal  +  ; 

wasting  +  ;  percussion  note  impaired  in  the  right  upper 


64  Radiography  of  the  Chest 

lobe :  sent  to  X-ray  department  as  incipient  tubercle  (?). 
Radiogram  58,  cardiac  outlines  of  mitral  stenosis  :  both 
pulmonary  fields  pervaded  by  the  fine  mottling  of  diffuse 
fibrosis :  emphysema  in  both  lungs,  with  a  tendency  to 
the  paralytic  thorax.  On  the  right  side  of  the  intra- 
thoracic trachea  a  thickened  line,  ending  below  in  a 
slight  enlargement  (Crane's  inverted  comma),  which  is 
to  be  regarded  as  a  fibroid  metamorphosis  of  one  of  the 
deeper  tracheobronchial  glands.  The  comma  with  its 
prolongation  (fibrosed  lymphatic)  is  a  guide  to  the 
right  border  of  the  trachea.  In  Radiogram  37,  Chapter  V, 
mitral  stenosis  is  accompanied  by  a  nodular  arrested 
tubercle. 

For  the  sake  of  comparison  two  cases  of  pneumoconiosis, 
due  to  the  inhalation  of  organic  dust,  are  depicted  in 
Radiograms  59  and  60. 

{a)    Henry    T ,    aet.    48.      French   polisher :   has 

suffered  from  asthma  for  five  months  :  heart  apex  beat 
normal :  chest  emphysematous :  rhonchi  diffused  through- 
out both  lungs.  The  Radiogram,  No.  59,  show^s  emphy- 
sema, phrenic  leaflets  flattened :  heart  vertical  and 
median :  mediastinum  slightly  deviated  to  the  left :  a 
fine  network  of  fibrosed  tubes  most  marked  in  the  right 
lung  :  slight  general  dilatation  of  the  right  bronchi :  both 
hilar  opacities  enlarged  and  fibrous.  The  resemblance, 
and  at  the  same  time  the  distinction  from  interstitial 
fibroid  tubercle,  are  noticeable. 

The  affinity  of  this  case  with  tubercle  is  exceedingly 
remote.  Occasionally  in  the  elderly,  tubercle  becomes 
grafted  upon  pneumoconiosis  (fibro-tuberculous) ;  when 
this  occurs  the  infection  often  occupies  the  right  upper 
lobe,  or  it  may  be  interlobar.  In  the  latter  event  the  ap- 
pearance of  bacilli  in  the  sputum  may  be  considerably 
delayed. 

{b)  Peter  H ,  set.  21.     Has  worked  in  grain  for  four 

years.  Clinical :  cough  +  :  expectoration  +  :  Tbc.  4-  : 
percussion  dulness  impaired  on  the  right  side  in  front 
and  behind  :  rhonchi  right  lung  in  front  and  both  bases 
behind:  no  clubbing.  Radiogram  60,  the  right  hilar 
opacity  is  very  large  (a  characteristic  of  dust  disease), 


KaciriK  p.  04. 


1 


Facing  p.  64. 


Radiography  of  the  Chest  65 

and  contains  dilated  tubes :  old  infiltrations  at  the  right 
apex  with  excavations  (only  seen  distinctly  on  the 
plate) :  a  pronounced  general  striation — possibly  disease 
in  this  instance  first  tuberculous,  then  pneumoconioid. 

In  coal  miners  the  inhalation  of  carbon  dust  is  said  to 
play  an  important  part  in  the  production  of  dense  fibroid 
phthisis.  On  the  other  hand,  the  researches  of  Tripier 
and  others  seem  to  establish  the  inverse  relation^  namely, 
that  pulmonary  tuberculosis  induces  the  production  of 
pneumoconiosis  in  dust  workers  ;  the  presence  of  the  dust 
hinders  the  development  of  existing  tubercle,  and  converts 
what  might  become  an  ordinary  common  phthisis  into  a 
mild,  very  slowly  progressive  fibroid  form.  In  other 
words,  it  is  tuberculo-fibroid  in  character  {vide  Vol  II); 
and  therefore  only  occurs  in  miners  already  aff"ected  with 
tuberculosis.  A  similar  line  of  thought  may  be  suggested 
with  regard  to  alcoholism  and  specific  disease  when  asso- 
ciated with  tubercle. 

(5)  In  the  cavitary  forms  par  excellence,  the  excavations, 
when  apical,  may  possess  adequate  drainage  through  the 
bronchi,  may  become  empty,  dry,  surrounded  by  a  thick 
capsule,  and  comparatively  innocuous.  Their  outlines 
may  remain  perfectly  regular  and  oval  for3'ears  ;  they  may 
contract,  or  may  again  become  enlarged,  eroded,  and  ragged 
as  the  result  of  mixed  infection. 

{a)  Henry  H ,  aet.  34.      His  illness  began  with  an 

influenza  cold  two  years  ago  :  cough  +  :  expectoration  +  : 
Tbc.  +  :  t°  97^-98  •4*'.  Clinical  signs,  percussion  note 
impaired  at  both  apices  with  crepitations.  Clinical  diag- 
nosis :  pulmonary  tuberculosis  of  both  apices,  quiescent : 
Radiogram  61,  one  large  cavity  in  each  axillary  region, 
•'silent"  and  unrecognised  by  stethoscope,  with  fibroid 
induration  surrounding  each.  Small  nodes  in  each 
supraclavicular  apex.  On  each  side  the  disease  reaches 
nearly  to  the  level  of  the  hilum.    Heart  median,  narrow. 

{b)    Horace    G ,     aet.  36.*      Ex-soldier:    Clinical: 

influenza  1918,  five  weeks  in  bed  :  at  end  of  second  week 
haemoptysis,   half-a-pint ;   in   1916  haemopt3'sis,    i   pint: 
"  In  more  advanced  stages  of  this  variety  the  greater  part  of  one  or  both 
fields  may  exhibit  a  similar  radiographical  appearance. 

F 


66  Radiography  of  the  Chest 

cough  +  :  wasting  +  :  t^  97 "4°  :  dulness  both  apices: 
isthmus,  right  3",  left  2V :  paravertebral  dulness :  no 
adventitious  sounds.  Radiogram  62A,  areas  of  nodular 
fibrosis,  small  consolidations  and  small  irregular  exca- 
vations at  both  apices  :  disease  advancing  towards  the 
base  on  the  right :  heart  median  :  basal  emphysema. 

{c)  Olivia  B ,  62B,  aet.  13.    An  example  of  marked 

bilateral  fibroid,  with  cavitation  in  both  upper  lobes  : 
in  the  large  cavity  on  left  the  openings  of  the  bronchi 
are  visible,  and  it  is  crossed  by  the  axillary  border  of 
the  scapula  :  there  is  increased  deviation  of  the  heart  to 
the  left,  and  laevo- mediastinum.  A  few  broncho- 
pneumonic  nodes  are  visible  in  the  middle  of  the  right 
lung.  The  patient  succumbed  during  the  spring  epi- 
demic of  influenza,  1919. 

{d)  Fred.   B ,  aet.   13.     An  example  of  unilateral 

fibroid  phthisis  (?) :  wasting  +  :  coarse  features  : 
dyspnoea  +  :  nails  incurved  :  sputum  copious  :  night 
sweats  — :  apparent  onset  four  years  ago  :  heart  beats 
felt  outside  right  nipple  line  :  cavitary  signs  in  front  at 
the  base :  over  the  back  rales  in  right  lung  :  bronchial 
breathing  and  bronchophony  at  the  left  apex :  crepita- 
tions at  the  left  base  (consolidation?):  moist  crepitations 
over  the  right  side  in  front.  Clinical  diao;nosis:  fibrosis 
(tubercle  ?)  of  right  lung.  Radiogram  63A,  anterior : 
right  lung  contracted :  left  hypertrophied,  reaching 
middle  line  at  cardiac  apex :  dextro-cardia :  dextro- 
mediastinum  :  dextro-trachea  :  on  right  side  upper  arrow 
points  to  the  ascending  aorta,  which  was  seen  beating  in 
the  middle  of  the  right  pulmonary  field  :  the  lower,  to 
the  bifurcation  of  the  trachea  :  on  the  left  side  the  arrows 
indicate  the  aorta,  and  the  scoliosis  cardiac  apex. 
Posterior  Radiogram,  63B,  the  middle  of  contracted 
right  chest  is  occupied  again  by  ascending  aorta  :  a  large 
apical  cavity  (arrows)  :  bifurcation  of  trachea  on  right 
of  spine  (arrows) :  several  small  cavities  and  dilated 
tubes  below  :  cardiac  outlines  blurred.  Patient  seen 
again  two  years  later ;  he  has  put  on  weight,  has  now  a 
healthy  complexion,  and  is  in  some  light  employment. 
The  radiographic  appearances  are  unchanged.  This 
case  may  be  one  of  pure  fibroid  lung  :  the  apical  cavity 
has  thin  walls  and  may  be  bronchiectatic.  Final  diag- 
nosis: Pure  fibroid  lung,  bronchiectasis. 


to 


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Facing  p.  66. 


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Radiography  of  the  Chest  67 

(e)  Emma  B- ,  aet.  55.     Has  complained  of  weak 

chest  for  twenty  years  :  had  attack  of  pleurisy  ten  years 
ago,  and  was  tapped  several  times  :  cough  +  :  expect- 
oration +  :  Tbc.  +  (six  years  ago) :  complexion  good  : 
suffers  from  dyspnoea  :  does  not  appear  tuberculous, 
and  has  preserved  weight.  Posteriorly,  dulness  to  per- 
cussion throughout :  on  left  side,  commencing  above, 
increasing  signs  of  cavity,  very  marked  at  base  (broncho- 
phony, whispering  pectoriloquy,  amphoric  breathing) : 
■on  right  side  expiration  prolonged  :  no  moist  sounds. 
Radiograyn  64,  large  cavity  in  left  apex,  laevo-trachea 
and  its  bifurcation  (arrows)  :  increased  deviation  of 
heart  to  left  :  crossing  of  right  lung  to  left  of  spine  : 
irregular  cavity  at  right  apex — perfectly-  oval  when 
radiographed  in  1913 — six  years  ago.  The  important 
features  are  the  marked  cavitary  physical  signs  at 
base,  instead  of  at  the  apex  (acoustic  anomal}-),  and 
its  evolution  which  is  not  entirely  stationary.  Apart 
from  the  ragged  excavation  at  right  apex,  and  the 
entrance  of  the  right  lung  into  the  left  chest,  the  con- 
dition is  in  statu  quo.  Prognosis  is  more  favourable 
when  the  right  lung  is  intact.  Lateral  scoliosis  is 
present  of  the  same  degree  as  before,  convex  to  the 
right.  There  is  still  a  liability  to  winter  colds  and 
slight  attacks  of  haemoptysis.  As  regards  its  precise 
position,  the  case  probably  corresponds  to  the  post- 
pleuritic  fibro-caseous  (cavities)  type  of  Bard,  with  a 
supplementary  slozvly  progressive  fibrosis  and  somewhat 
favourable  prognosis.  Moreover,  the  patient's  environ 
ment  is  perfect. 


68  Radiograpky  of  the  Chest 


CHAPTER  VII. 

Pneumonic  Phthisis  :  Miliary  Phthisis. 
I.   Pneumonic  Phthisis. 

Pneumonic  Phthisis  {Pneumoriia  caseosa),  as  in  other  types 
of  pulmonary  tubercle,  may  be  acute,  subacute,  or  chronic 
in  its  course.  Although  secondary,  as  a  rule,  to  fibro- 
caseating  cavitary  apical  phthisis,  it  may  occasionally 
originate  as  hilar  or  perihilar  disease  ;  in  the  latter  case 
evidence  of  old  apical  lesions  may  be  found  at  the  autopsy. 
When  a  consolidation  does  not  resolve  in  the  usual  manner, 
after  an  attack  of  pneumonia,  the  possibility  of  a  tuberculous 
infection  may  be  entertained,  even  if  no  bacilli  are  present 
in  the  sputum  :  the  explanation  of  a  well  marked  radio- 
logical opacity  present  in  the  lower  part  of  the  right  upper, 
in  the  middle,  or  in  the  basal  lobe,  which  remains  some 
time  after  the  clinical  symptoms  and  signs  have  become 
less  severe  or  have  disappeared  altogether,  is  often  a  very 
delicate  problem.  In  some  cases  it  is  obviously  a  fibrotic 
or  chronic  interstitial  pneumonic  shadow ;  sometimes  it 
may  be  due  to  a  collapse  fibrosis  after  bronchopneumonia, 
in  which  the  bronchi  will  become  dilated  eventually ;  in 
others  it  may  be  either  a  pure  pneumonic  or  broncho- 
pneumonic  residue  in  a  tuberculous  subject,  or  an  actual 
pneumonic  caseation  which  has  assumed  a  subacute  or 
chronic  phase.  It  may  be  necessary  to  examine  and  re- 
examine the  patient  at  intervals  of  two  or  three  months  by 
means  of  clinical,  radiological,  and  laboratory  methods 
before  arriving  at  a  final  and  satisfactory  solution. 

Tuberculous  pneumonia  is  characterised  post-mortem 
by  the  pres^ence  of  a  massive  lesion,  occupying  at  least  the 
whole  or  the  major  part  of  one  lobe  of  the  lung.  Death 
may  supervene  in  rapid  cases  in  the  stage  of  hepatisation 
before  any  material_^solution  has  occurred ;  or  there  may 


Radiography  of  the  Chest  69 

have  been  time,  as  generally  happens,  for  the  production 
of  diffuse  or  sinuous  excavation  of  the  caseating  mass.  As 
regards  the  clinical  features,  the  physician  at  first  probably 
considers  that  he  has  before  him  an  ordinary  lobar 
pneumonia,  until  he  finds  that  the  crisis  has  not  appeared 
at  the  end  of  the  second  week,  the  temperature  still 
ranging  between  103^  and  loi^,  while  the  weakness  and 
emaciation  are  becoming  more  manifest,  if  not  accelerated, 
and  the  physical  signs  of  crepitant  rales  and  cavernous 
sounds  still  persist.  The  clinician  may  then  suspect  the 
presence  of  an  encysted  empyema  or  of  a  massive 
pneumonia,  but  the  physical  signs  do  not  support  either 
impression ;  during  the  course  of  epidemic  influenza, 
the  possibility  of  a  subacute  migratory  bronchopneumonia 
may  be  suggested  ;  finally  the  sputum,  which  in  the  mean- 
time may  have  become  purulent,  is  examined,  and  a  few 
bacilli  may  be  found,  or,  if  possible,  the  patient  is  examined 
by  the  rays,  a  radiogram  is  taken,  and  the  problem  is 
solved.     (Vol.  II.) 

A  summary  of  the  essential  and  distinctive  features  may 
be  useful.  The  commencement  of  the  disease  is  rarely 
acute,  like  that  of  ordinary  lobar  pneumonia,  with  its 
rigor,  pain  in  the  side,  and  sudden  rise  of  temperature  to 
104°  ;  on  the  contrary,  there  has  usually  been  a  pre- 
liminary period  of  a  few  weeks  or  months  during  which 
the  patient  has  been  "  out  of  sorts,"  with  a  chronic  cough, 
headache,  loss  of  weight  and  strength  ;  and  he  has  become 
increasingly  dyspnceic.  In  some  instances  the  disease  is 
ushered  in  by  a  severe  haemoptysis,  which  renders  the 
diagnosis  clear.  The  sputum  may  be  stained,  gelatinous, 
viscid;  it  may  be  simply  mucoid;  when  the  lesion  softens 
it  becomes  mucopurulent,  and  finally  purulent.  Often  the 
sputum  is  non-bacillary  ;  in  the  case  of  Radiogram  65A  the 
bacilli  were  abundant  on  the  first  examination.  The  tem- 
perature curve  is  rarely  continuous,  but  intermittent  from 
the  beginning.  The  physical  signs  are  generally'  on  the 
right  side,  in  the  region  of  the  superior  interlobc,  above  it, 


70  Radiography  of  the  Chest 

or  at  the  bases  behind ;  occasionally  they  are  limited  to 
the  middle  lobe  in  front.  There  is  dulness  and  sub- 
crepitant  rales,  and  the  breathing  is  more  amphoric  than 
in  common  pneumonia.  On  the  healthier  side  there  may 
be  rhonchi,  or  the  signs  of  a  scattered  bronchopneumonia^ 
or  those  of  a  dry  pleurisy.  There  may  be  auscultatory 
evidence  of  the  existence  of  arrested  tuberculous  fibrosis 
of  the  right  apex;  sometimes  the  radiological  evidence  of 
apical  cavities,  with  or  without  stethoscopic  confirmation ; 
it  is  believed  that  these  cavities  act  as  resonators  in  the 
production  of  the  amphoric  breath  sounds.  This  concep- 
tion may  also  serve  to  explain  the  acoustic  anomalies  in 
Radiograms  64,  63A  and  63B.  Pneumonic  phthisis  is 
prone  to  occur  during  indigence  and  after  chronic  neglect 
of  healthy  conditions  of  living;  its  progress  may  be  so 
precipitate  that  death  occurs  within  three  weeks  from 
massive  toxaemia ;  more  often  it  runs  a  course  of  two  or 
three  months,  with  the  formation  of  cavities  and  gradual 
extension  to  the  other  lung ;  exceptionally  it  assumes  the 
chronic  form,  and  continues  as  an  ordinary  fibrocaseous 
phthisis. 

(a)  Frederick  O ,  aet.  24,  by  trade  a  fitter  :  two 

months  before  had  apparently  been  in  good  health:  now 
is  suffering  from  post-influenzal  pneumonia  :  cough  + : 
cyanosis  +  :  dyspnoea +:  pyrexia +:  clubbing  of  fingers 
+ :  Physical  signs :  crepitations  at  both  apices  :  behind^ 
dulness  on  both  sides  and  crepitations :  sputum  muco- 
purulent and  contains  numerous  bacilli.  Radiogram  65A  : 
at  the  lower  part  of  right  upper  lobe  a  dense,  practically 
homogeneous  infiltration,  reaching  nearly  to  clavicle,  and 
forming  nodal  opacities  below  in  right  middle  lobe  : 
signs  of  old  cavitation  in  the  right  infraclavicular 
apex(?):  disseminated  bronchopneumonic  patches  ex- 
tending from  the  left  hilum  towards  the  axilla  :  cardiac 
apex  slightly  retracted  towards  the  right,  or  possibly  a 
median  heart.  A  large  paratracheal  opacity  on  right 
border  of  the  intrathoracic  trachea,  not  clearly  separable 
from  the  pneumonic  consolidation  in  the  print,  but  easily 
on  the  plate  and  lantern  slide. 


u 


u 


Facing  p.  71. 


Radiography  of  the  Chest  71 

(b)  Radiogram  65B  (posterior),  was  taken  seven  weeks 
before  death.  In  the  right  middle  lobe  there  is  a  deep 
shadow,  with  a  definite  line  of  demarcation  above,  which 
is  practically  horizontal,  with  a  curved  outline  extern- 
ally :  internally  the  opacity  joins  that  of  the  heart.  In 
the  remainder  of  the  fields  a  few  scattered  nodules,  left 
supraclavicular  excavations,  thickened  and  dilated  hilar 
tubes.  Post-mortem  :  the  right  middle  lobe  was  almost 
completely  occupied  by  confluent  caseating  nodules  :  in 
the  h/t  apex  a  cavity,  about  the  size  of  a  hen's  Qgg,  ivith- 
out  thickened  walls,  and  somewhat  obscurely  seen  on  the 
plate.  Probably  radiograms  of  the  isolated  left  apex, 
ventral  and  dorsal,  would  have  brought  the  excavation 
more  clearly  into  view. 

{c)  Arthur  B ,   aet.   49   (6.5.19).      Family   history 

negative:  had  pneumonia  in  India  in  1895:  pleurisy  in 
1911:  influenza  in  October,  1918:  winter  cough  for 
fifteen  years:  expectoration  white  and  abundant:  haemop- 
tysis, streaks  the  week  before  admission :  emaciation, 
four  stone  :  night  sweats  — :  dyspnoea  +.  Clinical  signs: 
scattered  sibilant  sounds  behind  on  right  side  :  right  base 
dull  to  percussion,  and  no  breath  sounds  :  chest  rigid  : 
crepitations  in  left  lung:  96?-98'4*  :  Tbc.  negative: 
Radioscope  :  a  dense  opacity  in  the  right  middle  lobe, 
the  right  leaflet  of  the  diaphragm  almost  immobile. 
Radiogram  66,  anterior :  a  dense  shadow  continuous 
with  the  right  border  of  the  heart,  mapping  out  the  right 
middle  lobe,  with  a  lighter  streak  between  it  and  the 
diaphragm  corresponding  to  the  right  basal  lobe.  Dis- 
semination spreading  to  the  upper  right  lobe  and  to  the 
left  lung,  apparently  lymphatic  :  spreading  through  left 
hilum,  many  nodal  shadows  along  bronchus  running  to 
lower  lobe,  and  also  radiating  lines  running  towards  the 
left  apex.  The  posterior  view  showed  that  the  margins 
of  the  opacity  were  blurred.  The  diagnosis  lies  between 
bronchial  carcinoma  and  caseating  pneumonia  of  the 
right  middle  lobe.  The  absence  of  bacilli,  the  very 
pronounced  emaciation,  the  type  of  lymphatic  carci- 
nomatous dissemination,  with  very  few  nodular  foci,  the 
absence  of  pyrexia,  are  in  favour  of  neoplasm,  which, 
as  a  matter  of  fact,  it  proved  to  be. 

It  is  convenient  here  to  describe  the  somewhat  infrequent 


72  Radiography  of  the  Chest 

condition  of  fibroid  tuberculous  pneumonia  (phthisis  hyper- 
plastica  tuberculosa)  which,  according  to  Tripier,  follows 
a  prolonged  red  hepatisation.  Generally,  the  patient  is  a 
chronic  or  latent  consumptive,  who  is  attacked  by  a  lobar- 
pneumonia  which  does  not  resolve,  but  still  shows  the 
clinical  signs  of  a  persistent  fibrosis  (dulness,  bronchial 
breathing,  bronchophony).  The  disease  is  often  fatal 
within  six  months  or  a  year ;  although  there  is  radiological 
evidence  that  this  period  may  be  considerably  prolonged, 
and  the  consolidation,  when  it  affects  the  base  of  the  right 
upper  lobe,  and,  of  a  certainty,  when  it  is  also  accom- 
panied by  interlobar  adhesions,  may  shrink,  producing  a 
marked  diminution  of  the  three  upper  interspaces. 

{d)  William   R ,    aet,    46:  boot  maker.     Clinical: 

cough  for  years  :  now  worse  :  dyspnoea  +  :  Tbc.  +  : 
wasting  +  :  dulness  to  percussion  in  the  right  upper 
lobe:  crepitations  and  catarrhal  sounds  in  the  right 
upper  lobe  :  heart  not  displaced.  Clinical  diagnosis  : 
pleuritic  phthisis.  Radiogram  67,  consolidation  in  the 
lower  part  of  right  upper  lobe,  with  a  well  defined  lower 
edge  running  horizontally :  scattered  foci  present  along 
the  bronchi  of  middle  lobe  :  extreme  apices  free  :  signs  of 
excavation  in  middle  of  right  upper  lobe  (arrows) :  one 
arrow  points  to  a  very  large  Crane's  comma  :  calcifica- 
tion of  rib  cartilages  and  emphysema.  On  examination 
six  and  twelve  months  later,  little,  if  any,  change  was 
noticeable. 

II.  Miliary  and  Subtniliary  Tubercle. 
The  differentiation  of  general  miUary  tuberculosis  from 
malignant  endocarditis  and  lenteric  fever  —  the  two 
diseases  for  which  it  is  most  likely  to  be  mistaken — may 
be  at  times  very  difficult,  even  after  repeated  clinical 
examination,  assisted  by  the  most  elaborate  up-to-date 
refinements  of  laboratory  technique.  Under  these  circum- 
stances a  fluoroscopic  examination  alone  may  be  advisable, 
and  prove  of  valuable  service  ;  whilst  a  satisfactory  radio- 
gram, if  obtainable,  may  clinch  the  diagnosis.  Before  the 
ophthalmoscope  is  able   to  demonstrate  the  occurrence  of 


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Facing  p.  72. 

Radiography  of  the  Chest  73 

choroid  tubercles,  and  examination  of  the  urine  and 
cerebro-spinal  fluid  reveal  the  presence  of  the  bacillus  of 
tubercle,  the  fluoroscope  may  already  show  cloudy 
pulmonary  fields,  and  the  radiogram  manifest  the  conclusive 
signs  of  miliary  tuberculosis.  The  chest  may,  at  the  same 
lime,  disclose  very  little  information  on  physical  exami- 
nation :  the  lungs  may  even  be  quite  resonant  to  percussion, 
and  a  few  scattered  rales  only  may  be  audible  on  steth- 
oscopy :  whilst  the  incidence  of  functional  symptoms, 
such  as  extreme  dyspnoea  and  obvious  cyanosis,  may 
indicate,  nevertheless,  that  a  severe  pulmonary  lesion  does 
in  reality  exist. 

The  radiogram  shows  a  more  or  less  uniform  permeation 
of  both  lungs  by  innumerable  small  rounded  foci,  usually 
about  the  size  of  a  pin's  head,  sometimes  a  little  larger, 
■even  smaller;  occasionally  they  may  be  almost  concealed 
by  a  thin  diffuse  opacity,  due  probably  to  a  summation 
•effect  produced  by  the  maculae  situated  in  the  layers  of 
lung  lying  more  distant  from  the  plate.  A  great  deal  of 
discussion  has  taken  place  concerning  the  true  interpre- 
tation of  these  miliary  haematogenous  opacities ;  also 
concerning  the  differential  diagnosis  from  peribronchial 
disseminated  nodules,  miliary  carcinomatosis,  and  pneu- 
moconioid  flecks.  The  consensus  of  opinion  now  appears 
to  be  that  the  maculae  seen  on  the  radiogram  actually 
represent  the  size  and  topography  of  the  respective 
tubercles  which  lie  in  immediate  proximity  to  the  photo- 
graphic plate. 

The  granules  are  situated  for  the  most  part  in  the  walls 
of  the  alveoli,  in  connection  with  minute  vessels,  and  some 
may  develop  within  the  vessels  of  the  bronchial  wall. 
According  to  Bard  'there  are  cases  where  the  latter 
localisation  is  so  pronounced  as  to  merit  the  name  of 
bronchial  granule  (la  granulie  bronchique).  It  has  been 
stated  by  some  authorities  that  peribronchitic  foci  may  be 
distinguished  radiographically  from  pure  miliary  tubercles 
by  a  greater  tendency  to  aggregation  and  the  consequent 


74  Radiography  of  the  Chest 

formation  of  larger  opacities.  Although  this  occurs 
generally,  it  is  not  always  the  case.  Recourse  must  then 
be  had  to  the  clinical  data  {vide  page  75).  The  difficulty 
must  be  increased  in  the  genuine  broncho-vascular  miliary 
dissemination  just  mentioned.  If  the  plate  demonstrates 
at  one  apex  the  existence  of  an  imperfectly  evacuated 
cavity,  the  chances  are  that  we  are  dealing  with  an 
ordinary  disseminated  nodular  type  of  disease.  Both  true 
peribronchial  and  real  miliary  foci  are  best  seen  in  the 
middle  parts  of  the  chest  and  towards  the  scapular  areas. 
In  the  peribronchial  there  is,  nevertheless,  often  a  more 
crowded  appearance  in  the  upper  lobes,  and  the  foci  in 
these  situations  are  slightly  larger  in  size  and  more 
irregular  in  outline  than  those  in  the  remainder  of  the 
pulmonary  fields.  In  pulmonary  carcinomatosis  the  foci, 
though  small,  are  very  irregular  in  size,  and  the  age  of  the 
patient  and  the  presence  of  carcinoma  elsewhere  will  settle 
the  diagnosis.  (See  Vol.  II  for  radiogram  of  miliary 
carcinomatosis  of  the  lung.)  A  difficulty  may  arise  from 
the  co-existence  of  the  two  diseases  in  the  same  lung.  In 
pneumoconiosis  from  the  inhalation  of  inorganic  dust  the 
separate  foci  are  considerably  larger,  they  are  essentially 
perihilar,  and  there  are  massive  hilar  shadows,  particularly 
in  the  right  lung. 

{a)  Radiogram  68,  posterior:  the  pulmonary  fields  are 
filled  by  a  number  of  foci  of  pin-head  size.  At  the  right 
hilum  there  is  an  increased  shadowing  :  on  the  right  of 
trachea,  opposite  the  osseous  end  of  first  rib,  a  slightly 
convex  shadow  (arrow).  Post-mortem  examination : 
meningitis  tuberculosa :  the  lungs  permeated  by 
numerous  miliary  foci :  a  small  gland  the  size  of  a  bean 
reaches  about  1"  outwards  from  the  superior  vena  cava 
(softened  with  caseating  contents) :  at  the  right  hilum 
several  softened  and  one  large  caseating  gland.  The 
small  submiliary  foci  of  the  radiogram  correspond  to 
the  miliary  tubercles  of  the  lung  as  disclosed  by  the 
post-mortem.  The  caseating  gland  in  the  right  hilum 
and  that  on  the  right  side  of  the  S.V.C.  are  also  repre- 
sented on  the  radiogram. 


Rad.  69  (Post.)  -Miliary  phtliisis.    (Compare  witli  Rad.  68.) 


Facing  p.  75. 


Radiography  of  the  Chest  75 

Miliary  tuberculous  dissemination  may  be  to  some  extent 
localised  in  the  lung,  and  two  forms  have  been  described, 
(i)  The  asphyxial  form  of  Graves,  where  there  is  a  massive 
miliary  dissemination  throughout  the  lungs,  with  extreme 
dyspnoea,  due  to  the  mechanical  embarrassment  of  pul- 
monary oxidation,  and  negative  clinical  signs,  and  (2)  the 
catarrhal  form,  which,  according  to  the  intensity  of  the 
disease,  may  appear  {a)  bronchitic  with  the  signs  of  or- 
dinary bronchitis,  and  eventually  become  acute  local,  or 
generalised  tubercle :  {b)  capillary,  and  (c)  bronchopnen- 
monic,  in  which  the  physical  signs  resemble  those  of 
ordinary  disseminated  bronchopneumonic  tubercle  (Chap. 
III).  Possibly  the  more  severe  forms  are  sometimes  due 
to  the  irruption  of  a  caseating  bronchial  gland  at  the  hilum 
into  one  of  the  tributaries  of  the  bronchial  vein;  in  these 
cases  there  may  be  a  more  crowded  dispersal  through  the 
S.V.C.,  right  ventricle  and  pulmonary  circulation.  Miliary 
tuberculosis  of  the  lung  may  occur  after  measles,  pertussis, 
and  influenza,  with  which  increased  activity  of  tracheo- 
bronchial and  hilar  glands  maybe  associated.  After  these 
infectious  fevers  there  may  also  be  a  more  or  less  general 
cylindrical  bronchiectasia,  with  a  somewhat  copious  ex- 
pectoration. Pyrexia  is  irregular,  and  there  may  be 
morning  remissions,  wasting,  loss  of  strength,  and  enlarge- 
ment of  the  spleen. 

(b)  Elizabeth  F ,  aet.  15,  is  just  recovering  from 

pertussis :  there  is  a  somewhat  copious  (one  ounce  or 
more  per  diem)  purulent  expectoration,  devoid  of  bacilli : 
dyspnoea:  an  evening  t**  of  102°  or  103°,  with  morning 
remissions:  anaemia  :  pallor:  lossof  weight  and  strength. 
Physical  signs  insignificant  and  indefinite.  The  con- 
dition became  aggravated,  and  death  occurred  about 
eight  weeks  after  the  radiogram  was  taken.  The  latter 
(69)  shows  a  slight  diffuse  cylindrical  bronc^hicctasia, 
and  a  wide  distribution  of  small  foci,  particuhirly  in  the 
wings,  with  no  disposition  to  aggregation,  and  all 
practically  of  the  same  size. 

A  mild  curable  type  of  pulmonary  miliary  tuberculosis 
(tuberculosis  miliaris  benigna)  was  isolated  by  Pallard,  in 


76  Radiography  of  the  Chest 

1901.  He  described  18  cases,  the  diagnosis  of  some  being 
confirmed  by  autopsy.  The  patient  is  often  elderly,  or  at 
least  middle-aged,  complains  of  headache,  loss  of  appetite 
and  strength  for  perhaps  a  month  after  influenza,  bronchitis 
and  the  like.  There  may  be  a  fafnily  history  of  phthisis, 
and  the  patient  may  be  subject  to  winter  cough,  or  may  be 
•actually  suffering  from  mild  attenuated  or  chronic  fibroid 
tubercle  of  the  lung.  The  physical  signs  are  indefinite, 
perhaps,  at  one  apex,  usually  the  right,  there  is  tubular 
breathing  and  an  absence  of  adventitious  sounds  (fibrosis). 
Bacilli  may  not  be  present  in  the  sputum.  There  may 
occasionally  be  a  small  haemoptysis.  The  pyrexia,  which 
varies  from  102°  of  an  evening  to  98^  of  a  morning,  may 
last  for  three  weeks.  In  the  aged  the  course  is  often 
apyrexial.  In  one  case,  radiographed  by  the  author,  the 
patient  was  over  60  years  of  age,  was  ordinarily  thin,  but 
now  had  become  emaciated.  She  complained  of  severe 
headache,  and,  in  fact,  became  somewhat  peculiar  in  be- 
haviour and  disposition,  suggesting  a  dissemination  of 
foci  within  the  meninges,  a  possibility  which  does  not 
•appear  to  have  been  mentioned  by  alienists.  The  radio- 
gram showed  numerous  very  small  foci,  uniform  in  size, 
in  the  right  upper  lobe,  and  particularly  in  the  axillary 
region.  According  to  Pallard  these  foci  may  resolve 
completely,  or  produce  fibroid  specks,  which  may  unite  to 
form  patches  of  fibrosis. 

(c)  Arthur  H ,  ast.  47.     Illness  began  nine  years 

ago  with  pleurisy.  Physical  signs :  at  the  right  apex 
tubular  breathing,  increased  vocal  vibration,  no  added 
sounds  :  Tbc.  +.  The  Radiograms  (70A  and  70B)  show 
a  dense  infiltration  at  the  right  apex,  with  excavations 
better  seen  on  the  posterior  plate,  and  some  indurated 
patches  reaching  towards  the  hilum.  On  the  posterior 
radiogram  there  are  numerous  very  small  dark  foci, 
probably  fibroid  and  miliary,  which  appear  to  be 
■coalescing  to  form  a  festoon  below  the  dense  induration. 
It  is  possible  that  some  of  the  foci  are  pleuritic. 
:Stereo-radiograms  might  solve  the  question. 
Partial  miliary  dissemination  is  by  no  means  uncommon 


1 


FaciiiK  p.  76, 


Radiography  of  the  Chest  77" 

during  the  course  of  chronic  phthisis,  and  may  be  recog- 
nised on  the  radiogram. 

(a)  Radiogram  71  presents  difficulties.     James  J ,. 

aet.  65.  His  illness  began  three  weeks  before  the 
radiological  examination  was  made,  and  on  the  day 
following  a  severe  physical  and  accidental  strain,  in 
which  the  patient  was  compelled  to  sustain  for  a  short 
time  a  massive  weight,  fit  only  for  four  men  to  lift. 
Next  day  he  began  to  expectorate,  and  during  the  course 
of  the  same  day  he  had  a  haemoptysis  of  one  ounce  : 
then  slight  night  sweats  and  headache.  Auscultation 
was  indefinite.  The  radiogram  shows  aortic  sclerosis 
with  fusiform  dilatation,  a  narrow  heart,  somewhat  dense 
hilar  opacities  with  several  calcareous  nodes,  and  a  dis- 
tribution of  fine  foci  at  the  sides  of  the  chest.  On 
re-examination  four  weeks  later  these  had  disappeared,, 
leaving  slightly  clouded  areas.  In  the  radiogram  all 
the  foci  are  small,  they  show  no  tendency  to  aggregate  : 
a  few  run,  possibly  fortuitously,  along  the  bronchi  :  are 
they  miliary  or  bronchogenic  ?  The  rib  cartilages  are 
calcified,  and  the  chest  tends  to  assume  the  paralytic 
type. 


•yS  Radiography  of  the  Chest 


CHAPTER  VIII 

The  Complications  of  Pulmonary  Tuberculosis 
Pleurisy 

For  many  years  clinicians  and  pathologists  have  dis- 
cussed the  question  as  to  the  existence  of  primary 
tuberculous  pleurisy,  produced  by  the  autonomous  and 
independent  deposition  of  tubercles  within  this  serous 
membrane,  and  the  manner  in  which  the  infection  is 
carried  to  it.  The  possibility  of  its  occurrence  may  be 
admitted,  also  the  probability  that  the  bacilli  may  be 
conveyed  in  some  manner  via  the  lymphatic  circulation. 
Tuberculous  pleurisies  have  consequently  been  divided 
into  (i)  ^primary,  and  (2)  secondary.  The  former  have 
again  been  subdivided  into  {a)  the  superficial  and  {b)  the 
deep,  in  the  latter  of  which  the  subjacent  pulmonary 
tissue  participates.  The  secondary  pleurisies  arise  from 
tuberculous  lesions  occurring  in  the  neighbourhood — the 
lung,  the  ribs,  the  dorsal  vertebrae  and  the  peritoneum, 
or  they  are  the  result  of  a  widespread  infection  like  that 
of  generalised  miliary  tuberculosis.  In  the  primary  tuber- 
culous pleurisies  the  effusion  will  constitute  therefore  the 
first  radiological  manifestation  of  the  disease.  Radiological 
examination  made  before,  and  subsequently  to  the 
evacuation  of  the  effusion,  gives  no  support  to  the  view — 
either  active  tuberculous  foci  are  present  already 
within  the  lung,  or  there  is  ample  evidence  of  a  latent 
or  quasi-latent  tuberculous  infection  of  the  hilar  or  peri- 
hilar  areas.  For  these  reasons  the  so-called  post-pleuritic 
types  of  pulmonary  phthisis  (Bard)  are  more  accurately 
described  as  varieties  of  tubercle  in  which  pleuritic 
effusions  and  adhesions  impress  a  particular  character 
upon,  and  exercise  a  preponderating  influence  over,  the 
-evolution  of  the  disease.     The  following  case  illustrates 


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Radiography  of  the  Chest  79 

some  of  the  points  at  issue,  and  at  the  same  time  the  utihty 
of  radiological  examination  for  the  purposes  of  diagnosis. 

Case  i. — John ,  aet.  50.     Had  pleurisy  twenty  years 

before  :  haemoptysis  six  weeks  ago  with  night  sweats, 
pain  in  the  right  side,  dyspnoea  and  some  loss  of  weight. 
On  the  right  side,  in  front  and  above,  percussion  note 
impaired  :  vocal  resonance  diminished :  breath  sounds 
weak  :  right  side,  behind  and  below,  vocal  resonance 
increased  and  breath  sounds  loud.  Clinical  diagnosis  : 
unresolved  pneumonia.  Radiogram  72  shows  a  well 
defined  lower  edge  of  the  right  upper  lobe  with  an 
interlobar  pleuritic  thickening  and  adhesion  :  tuberculous 
infection  in  the  shape  of  thickened  dilated  tubes  and 
small  indurated  foci  in  right  upper  lobe  :  "  inverted 
comma"  conspicuous  along  the  right  border  of  the 
trachea  (arrow) :  some  general  cylindrical  bronchi- 
ectasia  and  indurations  along  certain  bronchi  of  the 
right  middle  lobe.  There  is  some  contraction  of  the 
right  upper  chest,  slight  deviation  of  the  heart  and 
mediastinum  towards  the  right  side,  and  irregularity  of 
the  outer  half  of  the  right  phrenic  leaflet  :  hilar  fibrosis 
on  the  left  side,  and  dilatation  of  tubes :  also  dilatation 
of  the  ascending  aorta. 

The  case  bears  some  resemblances  to  the  benign  type 
isolated  by  Piery,  and  termed  by  him  pleuritis  tuberculosa 
recidivans  (pleurite  tuberculeuse  a  repetition).  It  is 
possible  that  a  genuine  bronchiectasis  may  ultimately  be 
produced  beneath  the  interlobar  opacity. 

Secondary  pleurisies,  with  or  without  effusion,  occur  so 
frequently  during  the  course  of  pulmonary  tuberculosis 
that  they  may  be  regarded,  not  so  much  as  complications, 
but  as  a  natural  consequence  due  to  the  pla}'  of  the 
defensive  powers  of  the  organism.  Beside  the  pleurisies 
with  large  effusions,  one  often  meets  with  pleurisies  in 
which  the  effusions  are  insignificant,  commencing  in- 
sidiously, and  at  times  overlooked.  The  radiographical 
appearance  is  not  always  characteristic,  since  the  effusion 
may  occur  within  a  pleural  cavity  limited  and  deformed  by 
adhesions — moreover,   the   amount  of   fluid  may  not   be 


8o  Radiography  of  the  Chest 

sufficient  to  produce  displacement  of  the  heart  and  media- 
stinum, or  these  organs  may  already  be  fixed  by  previous 
disease.  As  a  rule  the  fluid  is  serous,  generally  basal,  and 
it  is  more  commonly  found  in  men  from  20  to  40  years  of 
age,  and  on  the  left  side. 

Case  2. — Richard  F ,  aet.    28  years  :  suffered  from 

pleurisy  ten  months  ago :  cough  +  :  expectoration  +  : 
Tbc.  +  :  dulness  and  loss  of  movement  at  the  left  base 
extending  above  the  left  nipple  :  crepitations  in  both 
upper  lobes  :  heart  apex  beat  not  found.  Diagnosis  : 
phthisis  of  both  upper  lobes,  with  effusion  at  the  left  base. 
The  Radiogram  (No.  73)  shows  a  disseminated  tubercle 
with  dilated  tubes  in  both  lungs  :  irregular  cavity  at  left 
apex  beneath  middle  of  left  clavicle :  excavations  (?)  in 
right  apex :  an  effusion  at  left  base,  the  upper  edge  of 
which  runs  upwards  and  outwards  :  slight  deviation  of 
right  auricle  to  the  right,  and  of  upper  mediastinum  to 
the  left.  A  metal  square  on  the  left  nipple  (seen  in  plate, 
not  in  print)  appears  in  the  middle  of  the  opacity.  On 
standing,  the  distance  of  the  upper  line  of  the  effusion 
from  the  disc  was  one  inch  higher  than  in  the  recumbent 
position. 

Collections  of  encysted  fluid  may  occur  in  any  part  of 
the  chest.  They  are  commonest  in  connection  with  the 
right  upper  and  lower  interlobar  fissures. 

Case    3. — Henry  F ,  set.   30  years  :  suffers   from 

cough  at  night :  expectorates  about  one  ounce  of  sputum 
per  day :  there  are  night  sweats :  a  temperature 
occasionally  100°  of  an  evening :  there  is  dulness  at  both 
bases,  crepitations  in  the  right  lower  lobe :  heart  not 
displaced.  Clinical  Diagnosis  :  chronic  pleurisy  with 
effusion.  Radioscopic  examination :  on  the  right  the 
diaphragm  moves  well :  there  is  an  area  of  dense  opacity 
at  the  right  base,  of  the  same  appearance  in  front  and 
behind  :  Radiogram  74,  a  large  encysted  effusion  at  the 
right  base  (connected  with  the  lower  fissure  ?),  thickened 
pleura  at  the  left  base  :  slight  deviation  of  the  upper 
mediastinum  and  trachea  to  the  left :  fibrosis  or  collapse 
of  the  middle  lobe  :  slight  illumination  at  the  base  due 
to  basal  lobe :  some  old  nodules  at  right  supraclavicular 


5 


^ 


a 


CL, 


Facing  p.  8o. 


Radiography  of  the  Chest  8i 

apex.    On  puncture  a  straw-coloured  fluid  was  obtained 
which  contained  tubercle  bacilli. 

Localised  adhesions  may  remain  after  the  absorption  and 
evacuation  of  effusions,  or  may  be  the  result  of  a  dry 
pleurisy.  Simple  thickenings  of  the  visceral  pleura  may 
occur  at  the  apices,  interlobes,  diaphragm,  and  in  the 
mediastinum.  Over  the  apex  they  may  form  a  thick  cap, 
concealing  deeper  lesions.  This  is  often  seen  as  an  opacity 
in  the  posterior  radiogram,  running  parallel  to  the  lower 
border  of  the  second  rib.  Pleuro-visceral  adhesions  at  the 
apex  may  lead  to  pain,  diminished  movement,  weak  breath 
sounds,  or  interrupted  breathing,  with  friction  sounds  and 
retraction  of  the  fossa.  The  opacity  in  the  supraclavicular 
region  may  be  more  obvious  posteriorly,  both  sides 
therefore  should  be  examined  by  the  rays.  If  basal, 
the  diaphragm  may  be  rather  sluggish,  but  on  its  descent 
should  show  a  narrow  band  of  opacity  parallel  to  its 
upper  margin. 

Thickenings  of  the  parietal  pleura  are  commoner  at  the 
base,  and  may  produce  adhesions  between  the  diaphragm 
and  the  ribs.  Costophrenic  adhesions  are  not  uncommon 
on  the  left  side.  Occasionally^  the  whole  of  one  half  of 
the  diaphragm  is  immobile  and  fixed  to  the  ribs,  producing 
dulness  at  the  base,  and  leading  to  the  clinical  diagnosis 
of  basal  effusion,  unresolved  basal  pneumonia,  or  basal 
fibrosis.  If  the  adhesion  is  slightly  yielding,  there  may  be 
an  inspiratory  tremor  in  the  diaphragm  without  descent 
(Radiogram  84).  Adhesions  of  the  diaphragm  to  the  ribs, 
the  remains  of  old  dry  pleurisy,  may  retain  the  diaphragm 
at  one  or  more  localities,  which  are  best  seen  during 
inspiration.  A  common  situation  is  at  the  level  of  the 
main  basal  bronchus  (phenomene  du  feston  diaphragm- 
atique,  Radiogram  41).  Mediastinal  adhesions  are  shown 
by  disfigurement  or  irregularities  of  the  cardiac  outline 
on  one  or  both  sides,  and  by  thin  shadows  below  the 
inner  end  of  the  right  clavicle,  running  parallel  to  the 
sternum.       Thickenings    limited    to    the  axillary   region 

G 


82  Radiography  of  the  Chest 

may  be  present  (Radiogram  57).     Cardiophrenic  adhesions 
are  common  {vide  Vol.  II). 

Diffuse  pleural  adhesions  (concretio  diffusa)  may  occur, 
obliterating  the  pleural  cavity,  with  or  without  thickening 
of  the  membrane ;  in  the  latter  case  there  may  be  little  or  no 
loss  of  transparency  on  the  radiogram.  The  diagnosis  then 
depends  on  the  position  of  the  ribs,  the  narrowness  of  the 
interspaces,  a  sudden  bending  of  the  ribs  in  the  axillary  line, 
scoliosis  of  the  spine,  the  convexity  towards  the  healthy 
side  (Radiogram  64),  abnormal  respiratory  movements, 
such  as  the  cradle  or  see-saw  movement  of  the  lower  part 
of  the  chest.  In  other  cases  diffuse  thickenings  (visceral?) 
may  occur  without  adhesion  when  the  whole  of  one  side  of 
the  chest  appears  opaque ;  occasionally  more  intense 
patches  of  opacity  may  be  seen  through  the  shadow,  due 
to  infiltrations  of  the  lung.  In  some  instances  the  opacity 
is  so  thick  that  nothing  can  be  ascertained  as  to  the  state 
of  the  subjacent  lung ;  moreover,  in  the  earlier  stages 
there  may  be  little  or  no  constriction  of  the  chest.  In- 
formation as  to  the  existence  of  tubercle  may  be  gained  by 
contrasting  anterior  and  posterior  radiograms,  and  by 
careful  examination  of  the  more  transparent  lung.  Fail- 
ing these,  recourse  must  be  had  to  laboratory  methods 
for  diagnosis. 

Case  4. — Mary  W ,  aet.  39,  has  had  a  weak  chest 

from  a  child  :  pleurisy  three  3Tars  ago,  ill  then  for  two 
months  :  pain  in  chest  :  cough  4-  :  expectoration  —  : 
dyspnoea  —  :  palpitations- :  night  sweating  +  :  wasting +  : 
at  left  base  dulness,  and  sinking  in  of  lower  ribs  below 
the  seventh  during  inspiration  and  movement  towards 
the  right  side  (see-saw  movement).  The  radiogram, 
No.  75,  shows  a  pleural  S3^mphysis  on  the  left,  in  which 
the  pleural  leaves  are  but  slightl}^  thickened,  and  fibrosis 
of  the  left  upper  lobe.  Re-examination,  after  eighteen 
months,  showed  an  improvement  and  a  diminution  of 
the  cradle  movement.  Scaphoid  scapula  on  left  (arrow). 
The  right  lung  and  hilum  show  changes  due  to  obsolete 
tubercle. 


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73 


Facing  p.  83. 


Radiography  of  the  Chest  83 

Pneumothorax 

Pneumothorax  is  one  of  the  difficulties  of  physical 
diagnosis,  one  of  the  easier  problems  for  the  radiologist. 
The  commonest  seat  of  tuberculous  pneumothorax  is  near 
the  diaphragm  in  the  axillary  line  (Radiogram  32),  and  its 
size  ma}^  vary  from  that  of  a  large  cavity  to  that  of  half  a 
lobe  of  the  lung:  in  certain  cases,  where  adhesions  are  not 
present,  the  whole  lung  may  collapse  and  appear  as  a  mere 
stump  at  the  hilum.  In  pulmonary  tuberculosis  this  is  rare, 
since  adhesions  are  practically  always  present  either  at 
the  base  or  at  the  apex  of  the  lung. 

Case   i. — Thomas  G ,  aet.    33.     Had  pleurisy  on 

the  right  side  one  year  ago:  has  had  pain  between  the 
shoulders  and  on  the  right  side  of  the  chest  :  at  the  right 
base  the  breath  sounds  are  faint,  vocal  resonance  is 
absent :  there  are  no  crepitations,  but  there  are  crepita- 
tions at  the  left  apex  :  heart  not  displaced.  Diagnosis  : 
undetermined  (because  pneumothorax  was  not  sus- 
pected). The  diagnosis  was  made  clear  at  once  by  the 
radioscope,  since  there  was  a  bright  area  of  illumination 
at  the  right  base.  Radiogram  No.  76  confirms  the  diag- 
nosis of  pneumothorax,  due  chiefl}-  to  collapse  of  the 
right  middle  lobe  with  a  disseminated  tuberculosis  of 
low-grade  activity,  and  congestion  in  the  left  lung. 

The  progress  of  recovery  of  the  lung  should  be  ascertained 
b}' repeated  radioscopical  examinations:  six  weeks'  rest 
may  be  necessar}'  for  complete  re-expansion.  The  same 
routine  should  be  emplo3-ed  in  cases  of  operative  pueumo- 
thorax  after  emp3'ema.  Very  often  patients  are  sent  out  of 
hospital  with  one  lung  half  collapsed,  since  the  surgeon 
does  not  think  of  its  condition.  Sometimes  in  cases  of 
spontaneous  pneumothorax  a  posterior  view  will  show 
how  the  right  middle  and  right  upper  lobes  separate 
during  inspiration  as  the  air  enters  the  collapsed  lung 
{vide  Vol.  II,  "Emp3'ema").  When  the  pneumothorax  con- 
tains fluid  insufficient  on  the  one  hand,  or  in  excess,  so 
that  audible  succussion  is  not  obtained,  the  physical 
diagnosis  is  still  more  difficult.     It  is  often  diagnosed  by 


84  Radiography  of  the  Chest 

skilled  clinicians  as  fibroid  lung.  The  radioscope,  the 
patient  being  in  the  vertical  position,  shows  a  clean  cut, 
horizontal  fluid  line,  an  air  space  above  it,  and  visible 
succussion 

Case  2. — Thomas  N ,  aet.  32  years:  cough  for  one 

year:  weakness:  emaciation:  tubular  breathing  at  right 
apex :  crepitations  both  apices  :  and  splashing.  Radio- 
gram No.  77  shows  a  right  hydro-pneumothorax,  about 
two-thirds  full,  with  excavations  at  the  left  apex. 

These  effusions  are  usually  left  alone,  unless  symptoms, 
such  as  urgent  dyspnoea  and  distressing  cough  are  present. 
The  absorption  of  the  fluid  usually  requires  a  considerable 
time — maybe  six  months  or  more — and  leaves  behind  it 
a  greatly  thickened  pleura,  the  horizontality  of  the  upper 
margin  of  the  opacity  becomes  lost ;  it  may  now  run 
obliquely  upwards  and  outwards. 

In  pneumothorax  there  is  generally  a  marked  inspiratory 
deviation  of  the  mediastinum  towards  the  diseased  side,  and 
in  the  erect  position,  if  fluid  be  present,  and  the  cavity 
not  more  than  one-third  full,  the  level  of  the  effusion  rises 
during  the  same  period  of  respiration.  If  empty,  certain 
curious  paradoxical  movements  of  the  diaphragm  are 
observed  (z/f^^  Vol.  II,  "Pneumothorax").  Metallic  tinkling 
is  not  frequent  in  pneumothorax — about  30  per  cent.  It  has 
been  attributed  to  the  dropping  of  fluid  on  the  surface  of  the 
effusion,  or  to  the  bubbling  of  air  ascending  through  the 
liquid  during  inspiration  from  a  fistulous  tract  in  the  lung 
situated  beneath  the  level  of  the  fluid  (Norris  and  Landis, 
p.  129).  Since  this  tinkling — it  has  been  compared  to  the 
sound  produced  by  the  falling  of  grains  of  sand  into  a 
wine  glass — may  be  audible  in  a  pneumothorax  devoid  of 
fluid,  and  also  in  operative  pneumothorax  after  empyema, 
where  there  is  no  doubt  as  to  the  integrity  of  the  visceral 
pleura,  the  above  explanation  does  not  satisfy  all  cases. 
Skoda  and  other  authorities  also  have  considered  the 
presence  of  fluid  unnecessary  for  its  production.  They 
thought  it  might  be  due  to  the  propagation  of  mucous 
rales  through  an  air  chamber  acting  as  a  resonator.     It 


Rad.  77  (Ant.)     RiKlit  pncumothonix  with  ofTusion.     Cavitation 
left  apex. 


FacinK  p.  84. 


Radiography  of  the  Chest  85 

is  heard  during  inspiration,  coughing,  and  change  of 
position.  In  one  case,  without  fluid,  auscultated  by  the 
author,  it  was  heard  best  just  over  the  displaced  and 
mobile  mediastinum,  so  that  it  is  possibly  due  to  the 
stretching  of  adhesions  produced  by  the  inspiratory  move- 
ment of  the  mediastinum  itself  The  heart  and  mediastinum, 
unless  fixed  b}'  adhesions,  are  pushed  over  towards  the 
healthy  side  ;  this  is  more  obvious  when  the  pneumothorax 
is  on  the  left.  In  some  instances,  especially  in  artificial 
pneumothorax,  the  mediastinum  yields  at  one  of  its  two 
weak  spots — one  in  front  of  the  ascending  aorta  between 
it  and  the  sternum — a  bulge  appearing  on  the  healthy 
side:  or  just  behind  the  heart  about  the  level  of  the  eighth 
or  ninth  vertebra  ;  a  protrusion  then  appears  at  the  base. 
These  may  be  termed  the  superior  and  inferior  ballooning 
of  the  mediastinum.  The  complication  ver}^  rarely  happens 
in  spontaneous  pneumothorax  ;  the  author  has  seen  one 
case  where  superior  ballooning  occurred. 

It  has  been  already  stated  that  the  radiogram  may 
exhibit  calcareous,  obviously  subpleural  foci,  in  the  near 
vicinity  of  a  spontaneous  pneumothorax  (R.  32  and  R.  y6)\ 
at  other  times  such  foci  are  not  obvious.  In  Rad.  y6 
there  is  a  slight  deviation  of  the  heart,  so  that  the  vertebral 
column  is  just  visible.  The  absence  of  deviation  to 
palpation,  in  cases  of  right  pneumothorax,  may  mislead 
the  clinician,  since  the  heart  may  be  originally  median, 
with  little  protrusion  to  the  left,  a  circumstance  which  is 
frequent  in  tubercle. 

Emphysema 

During  the  progress  of  pulmonary  tuberculosis  the 
chest  may  assume  an  inspiratory  emphysematous  position, 
or  the  ribs  may  sink  and  the  interspaces  become  narrow, 
producing  the  flat  chest  (thorax  aplati  or  paral3'ticus). 
Also  partial,  vicarious,  or  compensatory  emphysema  is 
common.  Compensatory  emphysema  is  limited  to  par- 
ticular areas ;  for  example,  a  single  or  double  apical 
tuberculosis    may    lead    to    dilatation    of    the    bases,    and 


86  Radiography  of  the  Chest 

finally  to  emphysema.  In  other  cases  there  may  be  a 
localised  apical  emphysema,  especially  in  women,  and  par- 
ticularly involving  the  second  right  interspace.  Occasion- 
ally the  middle  chest  is  expanded  (annular).  Localised 
and  diffuse  emphysema  may  be  associated  with  many  non- 
tuberculous  affections,  such  as  chronic  bronchitis,  atheroma, 
and  dilatation  of  the  aorta,  myocardiac  degeneration,  and 
pressure  on  the  main  bronchi  by  neoplasms  and  aneurysms ; 
but,  as  a  general  rule,  double  hypertrophic  emphysema  is 
paratuberculous ;  in  other  words,  it  is  to  be  regarded  as 
the  outward  expression  of  a  chronic  pulmonary  tuber- 
culosis. The  radioscopical  and  radiographical  features  are 
given  in  greater  detail  in  the  second  volume ;  a  few  of  the 
salient  characters  are  mentioned  here.  In  all  cases  the 
crural  as  well  as  the  sternocostal  halves  of  the  diaphragm 
must  be  examined ;  in  well  marked  cases  of  emphysema, 
while  the  sternocostal  or  frontal  diaphragm  is  flat,  deep, 
and  practically  immobile,  the  crural  or  posterior  diaphragm 
may  be  working  well.  In  very  severe  cases  of  generalised 
emph3'sema,  occurring  in  old  asthmatics,  and  after  serious 
gas  attacks  in  young  men,  the  crural  diaphragm  may  also 
lose  its  movement  and  may  be  pushed  down.  Under  these 
conditions  there  is  a  condition  of  complete  diffuse  hyper- 
trophic emphysema ;  a  central  or  perihilar  emphysema  is 
superadded,  and  the  dyspnoea  becomes  extreme.  As  a 
contrast  to  this  condition,  very  occasionally  one  sees  a  case 
of  apparent  emphysema  where  the  sternocostal  and  costal 
diaphragms  show  little  or  no  abnormality  either  in  move- 
ment or  position.  They  are  difficult  to  explain  ;  possibly 
they  are  due  to  a  loss  of  elasticity  in  the  bronchi  alone, 
which  produces  a  general  cylindrical  bronchiectasia. 

On  the  radiogram  a  variety  of  tuberculous  conditions 
are  associated  with  well  marked  emphysema,  {a)  enlarged 
hilar  and  paratracheal  opacities,  either  with  or  without 
cylindrical  bronchiectasis ;  {b)  basal  emphysema  may 
develop  in  the  presence  of  ordinary  apical  fibrocaseous 
disease,  and  in  the  absence  of  basal  pleuritic  adhesions  ; 


Radiography  of  the  Chest  87 

(c)  a  chest  originally  flat — thorax  paralyticus — scarcely,  if 
ever,  assumes  the  expanded  condition  of  emphysema, 
except  in  its  lower  parts.  The  ribs  do  not  run  quite 
horizontally  as  in  the  usual  cases  of  emphysema.  The 
asthmatic  chest  is  often  a  modification  of  this  form — very 
much  hyper-inflated  below,  with  enlarged  hila,  a  con- 
spicuous bronchial  arborisation  within  the  lung,  perihilar 
and  other  infiltrations  possibly  becoming  arrested,  or 
liable  to  recurring  attacks  of  perihilar  congestion,  with 
some  thickening  of  the  bronchial  walls,  and  a  median 
narrow  cardiac  opacity.  (d)  In  other  instances  there 
may  be  a  bilateral  disseminated  nodular  or  nodal  fibroid 
phthisis,  the  small  dark  and  irregular  maculae  and  nodes 
of  which  are  connected  by  a  fine  reticulum,  or  by  fibroid 
strings,  with  enlarged  hilar  and  fibrosed  right  para- 
tracheals.  Occasionally  the  disease  is  unilateral,  dis- 
seminated, or  dense,  and  the  healthy  lung  is  hyper-inflated 
only,  passing  across  the  spine  into  the  diseased  chest. 
As  the  result  of  radiological  observations  it  may  be 
suggested  that  (a)  diffuse  emphysema  is  primary  and 
inspiratory  in  origin  ;  that  {b)  calcification  of  the  first  costal 
cartilages,  instead  of  being  an  element  in  the  aetiolog}'^  of 
the  disease,  is  an  effect,  and  acts,  along  with  later  calci- 
fication of  the  lower  ribs,  as  a  safeguard  against  excessive 
expansion.  In  the  gas  poisoningof  soldiers,  where  emphy- 
sema may  become  extreme,  the  rib  cartilages  remain  quite 
soft  and  invisible  to  the  rays,  (c)  Rigidity  of  the  chest  in 
the  mean  respiratory,  or  in  the  expiratory  position,  in  the 
aged  is  due  to  the  presence  of  many  calcified  cartilages  ; 
in  the  young  adult  it  may  be  associated  with  an  extensive 
adherent  pleurisy. 

Haemoptysis 
may  be  an  early  event  in  pulmonar^^  phthisis  ;  it  may  occur 
on  several  occasions  during  the  course  of  the  disease,  or  it 
may  be  copious  and  terminal.  In  the  earlier  and  median 
stages  it  may  be  a  mere  staining  of  the  sputum,  an  insig- 
nificant spot,  a  minute    clot,  or  it  may  be  abundant  and 


88  Radiography  of  the  Chest 

amount  to  more  than  twenty  ounces.  Non-tuberculous 
sources  of  haemorrhage,  like  mitral  stenosis,  aneurism, 
bronchiectasis,  the  gums,  retro -lingual  varicosities,  the 
pharynx  and  fauces  (and  malingering),  are  usually  excluded 
by  the  ph3^sician.  It  is  not  considered  expedient  to  bring 
a  patient  to  the  X-ray  department  earlier  than  about  ten 
days  after  a  severe  attack  of  haemoptysis ;  during  this 
interval  any  changes  in  the  density  of  the  fields  may  have 
become  less  evident.  Nevertheless,  with  a  soft  tube  and  a 
short  exposure  it  may  even  then  be  possible  to  verify  the 
stethoscopic  localisation  of  its  source.  There  may  be  one 
or  more  caseating  foci  in  one  of  the  apices,  surrounded 
by  a  network  of  what  appear  to  be  not  bronchi  but  enlarged 
vessels — lymphatic  or  otherwise — there  may  be  the  remains 
of  an  interlobar  effusion  concealing  the  right  upper  lobe, 
which  disappears  after  some  few  weeks,  revealing  nodular 
foci  or  a  pneumonic  patch  beneath  ;  or  there  may  be  an 
irregular  fluff}^  area  of  infiltration  at  the  osseous  extremity 
of  the  first  rib  on  the  right,  which  suggests  an  active  con- 
dition. Such  instances  of  earlier  haemoptyses  may  there- 
fore be  termed  (a)  congestive,  (b)  pleuropneumonic,  and 
(c)  pneumonic.  In  the  early  congestive  forms  it  may  be 
the  accompaniment  of  mild  minor  phthisis  only,  with  no 
pyrexia,  no  bacilli,  and  an  appearance  practically  normal. 

On  reviewing  a  large  number  of  radiograms  of  cases  in 
which  haemoptysis  —  small,  medium,  and  severe  —  has 
occurred,  one  is  struck  (a)  by  the  fact  that  very  often 
localisation  of  the  bleeding  point  is  a  pure  speculation ; 
(b)  by  the  not  uncommon  occurrence  of  cloudy  irregular 
hilar  and  perihilar  or  interlobar  opacities  without  any 
other  changes ;  (c)  by  the  constant  association  of  small  or 
medium,  very  occasionally  severe,  haemoptyses,  with  the 
presence  of  disseminated  nodular  foci,  and  of  cavities 
within  the  apex  or  other  parts  of  the  lung;  (d)  and  by 
the  frequency  of  small  haemorrhages  in  the  fibroid  lung. 
In  the  two  latter  the  haemorrhage  is  probably  due  to 
erosion  of  arterioles  within  existing  cavities.     Very  often 


Radiography  of  the  Chest  89 

a  copious  haemorrhage  in  early  tuberculosis  connotes  a 
more  favourable  prognosis  than  frequent  streaking  of  the 
sputum  and  repeated  small  haemoptj'ses.  A  perusal  of  the 
radiograms  already  given  will  illustrate  these  paragraphs. 

Cavities 
are  recognisable  on  the  radiogram  by  their  thickened 
edges,  their  oval  shape,  their  central  translucency,  which 
may  approach  that  of  normal  lung,  and  even  surpass  it. 
Excavations  are  sometimes  found  at  the  autopsy  which 
are  invisible  on  the  plate,  because  their  edges  are  often 
thin  and  indefinable ;  they  may  be  uneven  and  ragged ; 
or  the  cavity  may  lie  in  the  midst  of  healthy  tissue. 
Sometimes  a  cavity  is  visible  in  one  radiogram,  usually  the 
posterior,  and  is  almost  or  quite  invisible  in  the  anterior ; 
it  is  therefore  missed  if  the  anterior  position  alone  is 
photographed.  In  other  cases  the  surrounding  tissue  is 
infiltrated  or  fibroid,  or  a  dense  layer  of  thickened  pleura 
covers  it.  If  the  cavitj'  is  partially  or  completely  full 
of  vascular  and  tissue  debris,  or  if  it  is  filled  with 
secretion,  it  is  not  clearly  defined.  An  enclosed  circular 
s|)ace  or  loculus,  clearer  than  the  rest  of  the  cavity  itself, 
may  be  due  occasionally  to  a  dilated  bronchus. 

Pleural  stripes  and  thickenings,  lung  cicatrices,  etc.,  may 
be  so  arranged  as  to  simulate  a  cavity  with  thickened 
wall ;  the  presence  of  lung  structure  within  the  circle  may 
settle  the  question  ;  optical  sections  of  dilated  bronchi, 
especially  in  the  perihilar  areas,  often  prove  a  difficulty. 
Opaque  infiltrations  within  the  supraclavicular  and 
infraclavicular  areas,  containing  oval,  so-called  clover- 
leaf-shaped  transparencies,  are  often  due  to  the  presence 
of  small,  old,  dry  excavations  ;  sometimes  they  are  dilated 
tubes,  at  other  times  genuine  cavities.  In  cases  where 
irregular  masses  of  induration  form,  the  excavations  appear 
as  sinous  and  irregular  transparencies  ;  in  some  instances 
these  are  dilated  and  tortuous  tubes. 

In  the  very  early  stages  of  a  cavity,  where  necrosis  of 
tissue  has  occurred,  without  solution  of  the  contents,  the 


90  Radiography  of  the  Chest 

presence  of  an  opaque  ring  is  characteristic.  The  interior 
may  appear  normal.  In  other  cases  the  annular  opacity  is 
incomplete,  and  may  remain  unfinished. 

Fred  S ,  set  23,  complains  of  cough,   dysphagia, 

wasting  :  no  adventitious  sounds  :   there  is  a  small  ulcer 
on  the  free  edge  of  the  epiglottis.    Radiogram  78 :  dis- 
seminated fibroid  tubercle  of  both  apices.     One  cavity  in 
each  apex,  probably  not  quite  empty,  and  the  commence- 
ment of  a  second  in  right  apex  below  the  first  (arrows). 
There  is  no  doubt  that  cavities  are  much  more  easily 
diagnosed  by  radiography  than  by  clinical  methods.     The 
former  shows  cavities  in  situations  where  they   may   be 
unexpected,  and  it  gives  precise  information — especially  if 
stereoradiograms  are  taken  —  of  their   size,   depth,  and 
contents.     If  quite  empty  the  prognosis  is  more  favourable 
(Chapter    III).      As   a   rule   no   clean-cut   fluid    level   is 
obtainable,  even  in  large  cavities — either  they  are  empt}', 
the  contents  are  semi-solid,  or  are  so  tenacious  that  they 
stick   to   the   wall.     Cavities  are  not   discernible   by  the 
stethoscope  unless  they  are  fairly   superficial,  reach  the 
size  of  a  walnut,  and  are  surrounded  by  infiltrated  tissue. 
As  long  as  they  do  not  contain  air  they  do  not  give  the 
usuah  physical  signs — only  subcrepitant  rales  and  seldom 
bronchial  breathing.     Until  they  are  thoroughly  emptied, 
there  is  always  the   danger  of  dispersal  throughout  the 
lung,  and  the  formation  of  new  tuberculous  foci  and  of 
laryngeal  and  intestinal  complications. 

The  thickness  of  the  wall  is  a  criterion  of  its  age.  A 
thick-walled  cavity  may  exist  unchanged  for  years  ;  but  if 
subjected  to  the  effect  of  mixed  infections  it  may  enlarge 
and  become  irregular  in  shape.  (Radiogram  64,  right  apex.) 
When  very  large,  a  cavity  may  be  mistaken  for  a  small 
pneumothorax.     (Vide  Wo],  II.) 

Bronchiectasis 
In   chronic   pulmonary   tuberculosis   dilatation   of  the 
bronchi  is  a  common  complication ;  sometimes  it  is  suffi- 
ciently advanced  to  constitute  a  true  bronchiectasis,  and 


_  to 
-r  O 


3    O 

Ok 


(z< 


Facing  p.  90. 


Radiography  of  the  Chest  91 

at  first  sight  may  mask  the  genuine  disease.  It  may  be 
present  as  a  general  cylindrical  dilatation  throughout  both 
lungs  ;  as  definite  bronchiectatic  cavities  at  the  base,  in 
exceptional  cases,  large  bronchiectatic  cavities  may  even  be 
found  in  the  upper  lobe.  A  sputum  examination  may 
reveal  the  presence  of  bacilli ;  in  other  cases  they  are 
continuously  absent,  when  the  suspicion  of  non-tuber- 
culous lesions  naturally  arises.  Clubbing  of  the  fingers 
accompanies  bronchiectasis,  whether  it  is  primary  or  if  it 
is  a  complication  of  tubercle. 

Mary  G ,  aet.  32,  has  suffered  from  cough  since 

childhood  :  and  now  from  a  winter  cough  for  years :  the 
sputum  is  scanty,  bacilli  are  absent,  the  weight  is 
stationary.  At  present  the  chief  complaints  are  cough 
and  great  lassitude.  Clitiical  signs:  creaking  sounds 
near  left  nipple,  dulness,  rhonchi  in  both  lungs,  crepita- 
tions at  the  left  base.  Radiogram  79:  several  dilated 
bronchi  (left  paracardiac)  just  outside  cardiac  apex  : 
thickened  tubes,  especially  the  right  paravertebral, 
throughout  both  lungs  :  emphysema,  particularly  of  the 
right  side:  a  slight  deviation  of  the  mediastinum  towards 
the  left :  and  the  general  appearances  of  old  arrested 
tubercle  in  both  lungs. 

It  appears  to  be  an  old  latent  perihilar  disease,  probably 
first  occurring  in  childhood,  in  which  the  typical  bronchi- 
ectatic sputum  has  never  developed,  but  the  lesion  has  left 
dilated  bronchi  as  the  clinical  indication  of  its  previous 
existence.  Several  of  the  previous  radiograms  show  the 
presence  of  a  cylindrical  generalised  bronchiectasia  (Radio- 
grams 17,  5o,  69,  etc.)  as  a  side-issue  of  the  genuine  tuber- 
culous disease  (Vol.  II,  "Bronchiectasis").  It  has  been 
already  stated  that  the  co-existence  of  the  two  lesions, 
especially  if  the  bronchiectasis  is  local  and  conspicuous, 
suggests  the  possibility  of  a  specific  infection. 


92  Radiography  of  the  Chest 


CHAPTER   IX 

The  Radiological  Diagnosis  of  Pulmonary  Tubercle. 

Preliminary  Observations 

Careful  perusal  of  the  foregoing  chapters  will  convince 
the  reader  that  in  several  forms  of  pulmonary  phthisis  the 
sputum  may  not,  and  probably  tiever  will,  contain  the  bacilli 
of  tubercle.  In  other  words,  there  are  numerous  cases  in 
which  the  lesions  are  permanently  closed. 

Secondly,  that  when  the  sputum,  previously  bacilliferous, 
becomes  free,  the  disease  may  be  neither  arrested  nor 
cured ;  and  thirdl}^  that  if  the  diagnosis  be  confirmed  by 
the  discovery  of  bacilli,  the  necessity  of  radiological  exami- 
nation still  continues  urgent.  By  means  of  the  latter  the 
locality  of  the  lesions,  their  extent,  their  attributes,  and 
the  type  of  the  disease  are  more  accurately  determined 
and  recorded.  In  many  instances,  unfortunately,  when 
the  sputum  is  positive,  no  attempt  to  ascertain  the  essen- 
tial quality  of  the  lesions  is  made  by  the  medical  examiner; 
at  the  same  time,  it  cannot  be  too  strongly  emphasised  that 
delay  in  pronouncing  a  patient  "tuberculous"  merely 
because  the  expectoration  furnishes  no  proof  is  dangerous, 
both  to  the  individual  himself  and  to  the  community  at 
large. 

When  properly  conducted  and  the  results  logically 
analysed,  in  so  far  as  the  peculiarities  of  acoustic  con- 
duction in  the  chest  are  understood,  clinical  examination 
is  of  the  greatest  value ;  but  if  the  apices  alone  are 
investigated,  whilst  the  deep  axillae,  the  interlobes,  and 
mammary  regions,  are  neglected,  mistakes  are  unavoidable. 
For  this  reason  alone  X-ray  examination  is  of  service; 
opacities  of  any  size  on  the  plate  are  at  once  recognised, 
even  by  the  less  experienced,  and  a  clinical  re-examination 
may  confirm  the  X-ray  observations.     By  the  use  of  both 


Radiography  of  the  Chest  93 

methods  a  mutual  control  is  provided,  and  difficult  pro- 
blems more  readily  solved.  On  the  other  hand,  the 
argument  has  been  seriously  advanced  that  radiological 
examination  leads  both  practitioner  and  student  into 
undesirable  habits,  so  to  speak ;  tends,  indeed,  to  make 
them  distrust  the  results  of  their  own  clinical  examination — 
in  reality  a  spontaneous  acknowledgment  of  the  value  of 
the  X  rays.  The  two  methods  are  dissimilar;  each  ap- 
proaches the  subject  from  a  different  point  of  view ;  it  is 
imperative,  therefore,  that  the  diagnosis  should  depend,  as 
far  as  practicable,  on  the  combined  and  corroborative 
evidence  of  both. 

The  additional  role  assigned  to  the  radiologist  is  the 
determination  of  the  character  of  the  plate;  whether  it  is 
under,  over,  or  accurately  exposed,  fully  or  incompletely 
developed  ;  whether  the  X-ray  tube  was  correct  in  qualit}', 
too  hard,  or  too  soft.  He  must  also  decide  what  is  normal 
and  what  is  pathological  on  the  radiogram  ;  in  the  latter 
event  he  must  differentiate  the  sharp  clean-cut  outlines  of 
old  arrested  lesions  from  the  cloudy  definitions  of  active 
disease.  It  has  been  asserted  that  one  may  be  uncon- 
sciously biassed  in  the  interpretation  of  the  radiogram  by 
a  knowledge  of  the  preceding  clinical  examination  ;  and 
conversely,  that  it  is  easy  to  find  dulness  on  percussing, 
rales  and  crepitations  on  auscultating  localities,  where 
obvious  opacities  are  present  on  the  plate ;  a  statement 
tending  to  cast  suspicion  on  the  utility  of  physical  examin- 
ation of  the  chest  in  general. 

Method  of  Examination 
Incidental  remarks  follow  concerning  the  clinical  signs 
of  the  different  forms  of  tubercle  :  these  are  appended 
because  the  radiologist  is  often  asked  to  examine  and 
report  on  patients  in  the  absence  of  clinical  data.  He  is 
expected  to  diagnose  the  case  just  as  if  these  had  also 
been  supplied  to  him.  The  examination  should  be 
systematic  and  orderly  :  (a)  the  history  of  the  patient 
carefully    recorded,    {b)    the    symptoms     enumerated,    (r) 


94  Radiography  of  the  Chest 

cHnical  examination  as  to  (i)  type  of  chest,  (a)  expansion, 
(3)  percussion  and  auscultation  of  apices,  axillae,  interlobes, 
interscapular  areas,  mammary  regions,  and  the  bases,  (4) 
radioscopy,  (5)  radiography,  (6)  a  second  physical  examin- 
ation of  anomalous  radiographical  opacities,  and  of  areas 
to  which  abnormal  intensities  of  striation  are  directed. 
Since  the  plate  is  actuall}^  the  sine  qua  non  for  the  purposes 
of  diagnosis,  it  is  unnecessary  to  spend  much  time  on 
radioscopy — after  the  outlines  of  the  heart,  the  condition 
of  the  hila,  the  extreme  apices,  the  movements  of  the  ribs 
and  diaphragm,  any  abnormal  opacities  have  been  observed 
from  different  points  of  view,  the  radiogram  should  be  taken 
forthwith  and  any  smaller  plates,  with  the  addition  of 
stereoscop}',  of  suspicious  areas,  if  expedient. 

Clifiical  Comments. 
It  is  said  that  (i)  lessened  expansion  of  one  upper  lobe, 
(2)  slight  increase  of  apical  tactile  fremitus  and  vocal 
resonance,  (3)  some  impairment  of  percussion  note  of  one 
apex,  (4)  prolonged  expiration,  (5)  post-tussive  inspiratory 
crepitations  in  the  upper  lobe,  are  the  earliest  signs  of 
tuberculous  infiltration.  Some  authorities  have  mentioned 
(i)  grminlar  breathing  at  the  apex  as  the  earliest  sign,  (2) 
feeble  breath  sounds  in  the  same  area,  or  over  the  whole 
of  the  affected  side,  (3)  interrupted  breath  sounds,  (4) 
slight  bronchial  breathing  and  whispering  pectoriloquy, 
followed  later  by  (5)  more  pronounced  bronchial  breathing, 
(6)  medium  sized  rales,  or  mucous  clicks — the  latter  of  which 
are  said  by  some  physicians  to  be  pathognomonic  of 
tuberculous  infiltration— and  (7)  showers  of  fine  inspira- 
tory rales  after  cough.  Difficulties  arise  in  the  clinical 
diagnosis  of  the  different  types,  whether  incipient  or- 
advanced,  e.g.,  of  the  fibrocaseating  bronchopneumonic 
cases,  and  in  particular  of  the  perihilar  varieties  of  this 
group ;  of  the  different  manifestations  of  minor  and  fibroid 
phthisis,  which  per  se  may  not  reach  alarming  proportions, 
but  which,  even  when  latent  and  obsolete,  leave  behind 
clinical  sequelae  which  subsequently  may  render  diagnosis 


Radiography  of  the  Chest  95 

uncertain.  Moreover,  classification  of  such  a  protean 
disease  as  phthisis  is  liable  to  become  obscured  by  the 
implantation  of  active  progressive  types  upon  ancient, 
apparently  obsolete  lesions.  In  the  fibroid  nodal  dis- 
seminated forms,  with  emph3'sema,  percussion  is  generally 
resonant  except  possibly  at  the  apex  (areas  of  fibrosis  or 
pleural  thickenings  and  adhesions) ;  rhonchi,  accompanied 
by  moist  rales,  are  often  heard  during  periods  of  temporary 
bronchitis  and  pulmonary  catarrh  ;  whilst  in  the  dissemin- 
ated nodular  forms  phj^sical  signs  are  extremely  feeble 
and  indefinite.  Apical  fixed  rhonchi  with  some  percussion 
dulness  are  associated  radiologicall}'  with  localised  minor 
fibroid  infiltrations  in  the  neighbourhood  of  dilated  tubes. 
Mucous  rales  are  present  also  in  caseating  pneumonia; 
and  along  the  borders  of  consolidations,  reactivated  by 
various  circumstances,  fine  rales  are  to  be  perceived.  The 
so-called  typical  tuberculous  rale,  due  to  softening  of  a 
caseous  focus,  is  moist,  generally  inspirator}',  increased  by 
cough,  is  localised  and  fixed  ;  whereas  the  mucous  rales, 
just  mentioned,  are  heard  over  wider  areas,  are  both, 
inspiratory  and  expiratory,  and  disappear  after  a  few  weeks 
medical  care.  Pleural  crepitations  are  dry,  superficial 
sounding,  present  both  during  inspiration  and  expiration, 
and  disappear  for  one  or  two  inspirations  after  cough. 
These  may  be  heard  in  many  latent  apical  fibroid  lesions 
in  middle-aged  individuals  who  seek  advice  for  extra- 
pulmonary disorders. 

The  clinical  signs  of  arrested  and  obsolete  tubercle  may 
include  flattening  and  diminished  expansion  of  one  or  both 
apices,  diminished  supraclavicular  areas  of  percussion 
dulness  (Kronig),  deficient  apical  respiratory  murmur 
harsh  breath  sounds  with  prolongation  of  expiration  at  the 
apices,  some  definite  bronchophony  and  whispering 
pectoriloquy  in  the  same  areas,  and  in  children,  telengi- 
ectases  around  the  cervico-dorsal  spines  (C7.  Dj.Dj.D,)  and 
elsewhere.  Of  these  clinical  signs  some  have  been 
regarded   as   indicative  of  incipient   and   active  tubercle. 


96  Radiography  of  the  Chest 

Piery  ascribes  the  idiminished  respiratory  murmur  to 
pleuritic  adhesions  ;  interrupted  breath  sounds  to  roughen- 
ings  or  irregular  thickenings  of  the  pleura ;  but  there  are 
other  causes  in  addition.  Harsh  breath  sounds  are  con- 
sidered by  the  same  authority  to  be  due  to  disseminated 
nodal  fibrosis  with  emphysema.  In  any  case,  many  of  the 
above  signs  are  certainly  inapplicable  to  the  real  beginning 
of  pulmonary  phthisis,  since  they  may  be  permanent  and 
not  followed  by  rales  and  crepitations.  The  radiological 
features  observed  under  the  above  conditions  also  vary — 
diminished  transparency  of  one  or  both  apices  (pleural 
thickenings  or  pulmonary  infiltrations),  weak  apical  breath 
sounds  (often  increased  hilar  opacities),  weak  breath  sounds 
at  base  or  generally  (diminished  traverse  of  one  or  both 
halves  of  the  diaphragm,  with  or  without  adhesions). 

Granular  breathing  may  be  associated  locally  and  radio- 
logically  with  an  aggregation  of  apparently  caseous,  fibro- 
caseous,  or  fibroid  opacities ;  in  many  cases  of  slight 
apical  bronchophony  and  whispering  pectoriloquy  there  is 
no  obvious  radiological  substratum ;  apical  mucous  clicks 
have  been  found  in  some  cases  of  marked  perihilar  lesions 
without  apical  changes  on  the  plate  (oedema  ?  from  pressure 
on  perihilar  veins  and  lymphatics) ;  also  adhesions  at  the 
base  have  giyen  rise  occasionally  to  the  clinical  diagnosis 
of  basal  fibrosis.  Mere  catarrhal  sounds,  rhonchi,  and 
sibili  are  not  necessarily  represented,  since  they  may  be 
due  to  simple  congestion  of  the  bronchial  mucous  mem- 
brane. The  slow  progressive  dissemination  of  small 
discrete  foci  from  the  hilum  towards  the  periphery  is  not 
likely  to  be  accompanied  by  definite  physical  signs. 

Pulmonary  Tuberculosis  in  the  Great  War 
Both  the  French  and  Italian  authorities  have  attacked 
the  serious  problem  of  the  tuberculous  soldier  in  a  com- 
prehensive and  satisfactory  manner.  The  latter — fortu- 
nately able  to  take  some  time  in  preparation — installed 
diagnostic  centres  {Reparti  di  accertamento  diagiiostico)  to 
investigate    all    cases.       Caccini    {Medical    Record,    191 8) 


Radiography  of  the  Chest  97 

describes  that  established  at  Rome.  The  Italian  medical 
boards  employed  rigorous  methods  for  the  purpose  of 
admitting  men  into  the  armies.  They  rightl}'  rejected 
those  with  a  history  of  past  pleurisy,  including  interlobitis, 
with  pleuritic  thickenings  and  adhesions,  the  relics  of  past 
disease.  At  first  it  was  thought  that  such  men  might  be 
utilised  in  the  auxiliary  services  ;  but  inasmuch  as  they 
are  only  able  to  give  a  minimum  of  work,  and  are  liable, 
under  the  periods  of  excessive  mental  and  bodily  strain 
imposed  by  military  necessity,  to  recrudescence  or  to  new 
manifestations,  it  was  considered  advisable  to  reject  them, 
except  under  special  conditions  of  urgency.  The  logical 
deduction  is  that  recruits  after  admission  must  be  con- 
sidered free  from  tubercle,  and  that  all  cases  of  tuberculosis 
arising  subsequently  must  be  regarded  as  caused  by  the 
vicissitudes  and  by  the  fatigue  of  warfare.  The  X  rays 
were  preferred  to  tuberculin,  and  radiography  fortunately 
took  precedence  over  radioscopy.  Stereoscopic  pictures 
were  taken  in  the  sitting  position,  with  the  tube  behind. 
The  data  were  divided  into  (a)  positive,  and  (b)  presump- 
tive. Positive  evidence  w^as  arranged  in  four  categories, 
viz.,  (i)  tubercle  bacilli  +:  (2)  larynx  +:  (3)  Tbc.  — :  signs 
+  :  X-ray +:  (4)  Tbc. —  :  signs  —  :  X-ray +  .  Examination 
of  the  larynx  is  indispensable,  since  tuberculosis  may  be 
active  in  this  situation  and  clinically  latent  in  the  lung. 
The  radio-signs  in  the  fourth  category  include  broncho- 
pneumonia and  pleurisy,  followed  to  their  possible  con- 
sequences ;  evidence,  however,  which  should  be  considered 
presumptive,  or  in  which  a  final  decision  should  be  post- 
poned (Author).  The  prcsinnptive  evidence  falls  under  three 
sections,  (i)  Tbc. —  :  signs  +  :  symptoms — :  X-ray  -f  :  (2) 
Tbc.  — :  signs  — :  symptoms  +  :  X-ray  +  :  and  (3)  Tbc. — : 
signs — :  symptoms — :  X-ray  +.  Under  section  3  the  X-ray 
signs  of  peribronchitis  and  bronchoadenitis  are  included ; 
signs  which  may  be  inconclusive  and  not  necessarily  tuber- 
culous (Autlior).  Soldiers  exhibiting  presumptive  evidence 
were  given  4-12  months  leave  and  then  re-examined. 
Those   with    minimal   signs   of   presumptive   proof  were 

H 


98  Radiography  of  the  Chest 

detached  for  sedentary  service.     The  French  Government 
also  estabHshed  a  probation  centre  for  each  army  {centre 
du  triage),  and  certain  of   the  results  have  already  been 
published.     The  examinees  consisted  of  soldiers  who  had 
undergone  military  service  and  had  been  subsequently  sent 
back  on  account  of  obvious  or  presumptive  tuberculosis. 
Emile  Sergent  and  Delamore,  of  the  Paris  centre,  reviewed 
600  cases  admitted   into  hospital  for  further  observation 
{Journal  de  Medecine,  1916).     After  complete  examination 
(repeated   clinical,    radioscopical   and    radiographical,    in- 
vestigation   of    sputum,    and    tuberculin    reactions,    tem- 
perature   charts,    blood    pressure    and    pulse),     14     per 
cent,  were  found   to  be  non-tuberculous.     Among   these 
were    cases    of    simple    anaemia,    emaciation,    dyspepsia, 
of  mitral    disease,    bronchitis,   and    emphysema.     About 
5    per    cent,    exhibited    nasal    lesions,    with    emaciation, 
anaemia,  cough,  the  absence  of  pyrexia,  of  increased  vocal 
vibrations,    and    of   fixed    adventitious    sounds,    with    the 
possession  of  normal  arterial  tension.     One  had  a  foreign 
body  in   the  lung,   another  a  hydatid   cyst.     Many  cases 
of  nasal    disease,  including    ethmoiditis,    antral    disease, 
hypertrophy   of  turbinates,    the    presence    of    spurs    and 
deflections  of  the  septum,  are  accompanied  by  a  chronic 
coryza  which  graduall}^  spreads    downwards,    leading  to 
granular  pharyngitis  and  bronchitis.    There  was  a  bacillary 
sputum  in   15    per  cent,  which  was  confirmed  by  physical 
and    radioscopic    examination.      Occasionally    the    latter 
showed  intrapulmonary  foci  and  cavities  which  the  stetho- 
scope was   unable  to   disclose  on  account  of  their  central 
and    deep    situation,    or     on    account    of    accompanying 
bronchitis  and  thickened  pleura.     In  70  per  cent,  of  the 
suspects  the  changes    were   apical,  and  in   about  50  per 
cent,    tuberculosis  was  active.      The   presence    of  paren- 
chymatous   apical   changes   was    shown    by   dulness    on 
percussion,  increased  vocal  vibrations,  crepitations,  haemo- 
ptysis ;  the  apical  opacity  being  unchanged  by  cough,  and 
being  accompanied  on  the  plate  by  the  presence  of  striae 
and  small  foci.     Pleural  adhesions  were  shown  by  dulness 


u 


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pL. 


Facing  p.  99. 


Radiography  of  the  Chest  99 

on  percussion,  diminished  tactile  fremitus,  pleural  friction 
sounds,  diffuse  opacity  with  some  illumination  on  cough. 
Sergent  also  gives  two  signs  in  addition,  viz.,  inequality  of 
pupils  (affected  side  usually  dilated)  and  supraclavicular 
adenitis  due  to  the  pleural  affection.  The  various  items  of 
the  pleural  syndrome  are  far  from  being  always  contem- 
poraneous, and  their  duration  is  as  variable  as  their 
frequency.  "  Les  frottements  sont  tres  precoses  et  tres 
fugaces  :  ils  traduisent  la  presence  d' exsudats  permeables 
aux  rayons  X  et  caracterisent  la  periode-  initiale,  purement 
stethacoustique  de  la  pleurite  apical e  .  .  .  les  voiles  qui 
resultent  del'organisation  des  adherences  conjonctives  sont 
plus  tardifs  et  plus  persistants;  ils  caracterisent  la  phase 
terminale,  essentiellment  radiologique,  de  la  symphj'se  du 
sommet."  These  statements  lack  anatomical  verification. 
Delherm  and  Kindberg  {Journal  dc  Radiologic  ct  d'Elcctro- 
logie,  19 1 7),  made  observations  on  one  thousand  cases  at  a 
probation  centre  in  France,  but  their  results  are  scarcely 
reliable,  since  they  considered  that  it  is  necessary  in  every 
case  to  place  in  evidence  the  bacilli  of  tubercle,  and  by  the 
fact  that  radioscopy  alone  seems  to  have  been  employed. 

REPORTS  OF  CASES  ILLUSTRATIVE  OF   PRECEDING 
STATEMENTS 

A. — Hilar,  Pcrihilar,  and  Interlobar  Lesions 

I.  James  S ,  aet.  22.     Cough,  haemoptysis,  ,^ii  fourteen  days 

ago:  Tbc+:  family  history  + .  Signs:  crepitations  at  both  apices, 
scattered  rhonchi.  Radioi^rani  80  :  both  hilar  opacities  increased 
in  size,  and  irregular  in  outhne:  right  paratracheal  opacity:  thick- 
ening and  dilatation  of  bronchi,  especially  in  upper  left  lobe,  some 
diminished  transparency  along  both  axillary  lines:  inliltration  of 
left  perihilum  :  small  subclavicular  foci  on  both  sides,  emphysema. 

3.  Caroline  H ,  act.  20.     Enlarged  tonsils,  especially  right : 

mouth  breather  :  cough  nine  months  :  expectoration  since  inlluenza 
six  months  ago:  hx'inoptysis,  an  occasional  staining:  no  night 
sweats:  Tbc. —  :  t°  subnormal.  Sii^ns:  left  isthmus  diminished: 
granular  breath  sounds,  some  rough  breathing  and  diminished 
expansion,  and  occasionally  a  few  crepitations  at  left  apex.  Radio- 
logical :  diaphragm  sluggish,  left  hilar  opacity  much  enlarged, 
diffuse  grey,  and  branches  running  to  left  upper  lobe  thickened  : 
median  microcardia. 


lOO  Radiography  of  the  Chest 

3.  Irene   S ,  set.   30.      Cough,    night    sweats,  emaciation^ 

marked  anaemia.  Clinical  signs  :  fixed  catarrhal  sounds  and  sHght 
cHcks  at  left  apex  :  breath  sounds  weak  at  the  right  base.  Radio- 
gram :  left  hilar  opacity  increased  in  size,  with  a  few  suspicious 
perihilar  nodes  between  it  and  left  apex. 

4.  John  M ,  aet.  13.     Expectoration  —  :  wasting  +  :  hccmo- 

ptysis —  :  looks  ill  :  left  chest — ,  dulness  to  percussion:  no  other 
physical  signs.  Radiogram  :  left  hilum  enlarged  with  an  indefinite 
periphery  :  thickened  bronchi  and  congested  vessels  running  to« 
left  apex  :  costophrenic  adhesion  at  cardiac  apex :  right  hilum 
enlarged,  bronchi  running  to  left  base  thickened. 

5.  Nellie  F ,  aet.  21.      Cough  three  months,  expectoration  : 

Tbc.  +  :  night  sweats:  pain  between  shoulder  blades  (interlobar?): 
t°  97-100°.  Physical  signs:  indefinite.  Radiogram:  right  upper 
interlobar  infiltration,  which  yields  dulness  to  percussion:  bronchial 
breathing  and  inspiratory  crepitations  on  auscultation — fissure  not 
examined  until  after  the  radioscopic  examination. 

6.  Daisy  D ,  ^et.  26.    Cough  and  pain  leftside  for  six  weeks : 

sputum +:  Tbc.  +  :  emaciation  slight.  Physical  signs:  movement 
and  percussion  not  diminished  left:  breath  sounds  feeble,  no  crepi- 
tations :  at  left  aj~ex  breath  sounds  rough.  Radiogram  81 :  cavity 
in  subaxillary  region  on  left :  a  few  infiltrations  between  it  and  left 
hilum.  Cases  like  this  are  not  uncommon.  They  may  leave  the 
sanatorium  improved  and  without  bacilli  in  sputum :  but  when  the 
lobe  containing  the  cavity,  or  one  of  the  other  lobes,  exhibits  what 
is  apparently  a  spray  of  congested  vessels,  small  hasmoptyses  (31) 
occur  with  change  of  barometric  pressure,  slight  unaccustomed 
exertion,  and  in  association  with  menstruation  (P.  congestiva). 
The  cavity  is  not  usually  visible  on  the  anterior  plate. 

B. — Apical  Infiltrations  with  or  without  Excavations  {on  Radiogram^ 

1.  Isabella ,  ret.  20.     Cough,  expectoration,  no  haemoptysis, 

dyspnoea,  wasting,  night  sweats,  family  history  positive  :  Clinical 
signs :  at  left  apex  diminished  movement,  feeble  breath  sounds,  no 
crepitations.  Tbc.  negative  (9  times).  Radiogram:  left  upper  lobe 
striated  in  appearance,  a  small  caseating  node  in  left  supraclavicular 
area  :  slight  left  lateral  microcardia. 

2.  Elizabeth   J ,  ret.  40.     Cough,  sputum  staining:   chronic 

cough  since  attack  of  pleurisy  and  hremoptysis  five  years  ago :  f* 
normal :  Clinical :  left  lung,  diminished  expansion  and  crepitations 
left  apex.  Radiogram  :  infiltrations  in  left  upper  lobe  reaching  as 
low  as  second  rib,  containing  small  excavations. 

3.  Thomas  D ,  ret.  37,  ex-soldier.     Gunshot  wound  left  lung, 

cough,  expectoration,  hremoptysis,  wasting,  dyspnoea.  Clinical  i 
breath  sounds  feeble  left  base,  no  adventitious  sounds,  vocal  fremi- 
tus increased.     Radiogram  :  fracture  of  left  ninth  rib  :  thickenings 


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Radiography  of  the  Chest  lor 

of  pleura  and  induration  of  lung  in  the  vicinity  :  infiltration  at  left 
apex,  apparently  old,  at  level  of  osseous  extremity  of  first  rib.  The 
symptoms  seem  due  to  the  traumatism  :  the  apical  lesion  has  not 
been  roused  into  activity. 

4.  Morris  L ,  ast.  46.     Pleurisy  eighteen  months  ago  :  cough 

for  years,  sputum  frothy,  haemoptysis  fortnight  ago,  emaciation  : 
family  history — .  Physical  signs:  slight  and  indecisive.  Radiogram: 
an  infiltration  in  right  first  and  second  interspaces,  outer  half:  no 
excavations:  right  paratracheal  opacity:  microcardia,  slight,  lateral 
and  to  right. 

C. — Disseminated  Lesions 

1.  Amy  G ,  ast.  29.  Began  to  be  ill  three  months  ago  :  flatten- 
ing and  diminished  expansion  left  side:  signs  indefinite  :  Tbc.  +  : 
Radiogram:  disseminated  nodular  in  both  lungs,  apparently  mainly 
fibrotic:  tendency  to  aggregation  at  apices:  dilated  thickened  tubes 
at  bases. 

2.  Albert  J ,  oet.  18.     Cough  one  year,  recently  left  pleurisy. 

Signs:  crepitations  behind  at  inferior  angles  of  scapulae,  dulness  at 
left  base.  Radiogram  :  disseminated  nodal  opacities  in  right  middle 
and  basal  lobe  :  thickenings  of  right  upper  interlobe  :  pleuritic 
residues  at  left  base  and  cardiophrenic  adhesion. 

3.  Edward  R ,  ret.   33.     Cough  for  years,  severe   influenza 

fifteen  and  again  ten  years  ago  :  cough,  h:emoptysis  on  three  occa- 
sions :  crepitations  and  rhonchi  in  right  lung.  Clinical  diagnosis  : 
bronchitis (?).  Radiogram  :  disseminated  nodular  phthisis  in  both 
lungs,  becoming  fibrotic:  mediastinal  deviation  to  the  right:  some 
dilated  tubes  in  right  upper  lobe. 

4.  Joseph  P ,  ivL  44.     Cough  and  expectoration  for  months: 

no  hx-moptysis:  emaciation.  Clinical  signs:  impaired  resonance  at 
left  apex,  a  few  rhonchi,  toneless  heart  sounds.  Radiogram  :  dis- 
.seminated  foci  and  small  cavities  left  upper  lobe,  nests  of  small 
foci  lower  down:  shrinking  of  left  upper  lobe:  central  micro- 
cardia. 

5.  Solomon   F ,  rtt.    46.     Severe  anorexia  and  emaciation 

four  years  ago :  occasional  pyrexia  100°:  no  physical  signs.  Tlie 
Radiogram  shows  a  widely  spread  crowded  distribution  of  very  small 
foci  in  both  lungs:  supraclavicular  apices  free:  ossification  of  first 
rib  cartilages. 

D. — Chronic  Infillrativc  Fibroid  Lnng 

I.  Catherine    E ,  a't.   33.      Cough,    dyspnoea,    tachycardi:i, 

dyspepsia.  Signs :  general  dulness  to  percussion  over  left  side, 
breath  sounds  and  tremitus  diminished,  in  places  breath  sounds 
tubular.  Systolic  bruit  at  cardiac  apex.  Radiogram  82  :  left  chest 
homogeneously  opaque,  excepting  a  darker  shadow,  only  seen  in 


102  Radiography  of  the  Chest 

view  box,  at  level  of  fifth  interspace :  laevo-trachea  :  mediastinum 
and  heart  slightly  to  right :  emphysema  of  right  lung  :  nipple 
shown — arrow:  shrinking  of  interspaces  on  left,  old  foci  in  right 
lung :  diagnosis  lies  between  pure  pleuritic  fibroid  lung  and  post 
pleuritic  fibroid  tubercle.     Wassermann  test  not  employed. 

2.  Albert  C ,  set.  52,  glass  worker.     Cough,  expectoration, 

dyspnoea.  B.P.  180/95.  Left  side  flat,  tubular  breath  sounds,, 
coarse  crepitations  and  clicks.  Clinical  diagnosis:  aneurism  or 
tubercle  (?).  Radiogram  :  opaque  patch  outside  left  hilum  reach- 
ing to  axilla,  and  a  thin  opacity  reaching  as  far  as  left  diaphragm 
from  lower  part  of  hilum.     Rad.  diagnosis:  pure  fibroid  (dust  ?). 

3.  Lily   C ,  ast.  39.     First  husband  and  one  daughter  died  of 

phthisis:  cough,  Tbc.  —  :  t°  subnormal  but  variable.  Signs:  crepi- 
tations both  apices.  Radiogram  :  fibrosis  of  lower  right  and  middle 
lobe:  emphysema:  dilated  right  auricle.  (Conjugal  tubercle  is  not 
uncommon;  it  is  often  perihilar,  of  minimal  activity,  or  arrested.) 

4.  Morris  M ,  aet.  45,  boot-laster.     Movement  on  right  side 

impaired  :  harsh  breath  sounds:  bronchial  breathing  :  dull  cracks 
in  front  and  back  of  upper  right:  Clinical  diagnosis:  fibroid  con- 
solidation right  upper  and  lower  lobes,  and  left  upper.  Radiogrant 
83:  consolidation  reaching  from  mediastinum  to  right  axilla  at 
level  of  second  rib  :  right  supraclavicular  area  opaque :  micro- 
cardia :  dilatation  of  ascending  aorta  and  sclerosis. 

E. — Midlohar  Fibrosis 

1.  Louisa  W ,  ret.  30.     Cough,  expectoration  slight,  wasting, 

flushed  face.  Signs:  percussion  impaired  on  right,  especially  middle 
lobe  :  Tbc.  — :  Radioscopy  :  diaphragmatic  movement  on  right 
minimal,  inspiratory  tremor  only  :  Radiogram  84  :  disseminated 
nodular  fibroid,  especially  affecting  right  middle  lobe. 

2.  Emily    G ,  aet.   28.      Cough,    sputum,    no   haemoptysis  r 

t°97'6°  :  Clinical :  diminished  movement,  breath  sounds  feeble,  no- 
crepitations  on  right  side.  Radiological :  right  hilum  enlarged, 
with  infiltration  extending  into  middle  lobe  :  some  deviation  of 
mediastinum  to  left.     Tuberculosis  or  unresolved  pneumonia? 

3.  A B.,  aet.  33.     Cough  one  year,  expectoration  streaked : 

Tbc. —  :  Clinical:  movement  and  percussion  note  impaired  right 
apex  :  granular  breath  sounds  in  hilar  region  posteriorly.  Radio- 
gram: fibrosis  middle  lobe,  and  heavy  hilar  opacity. 

F. — Pleuritic 

I.  Henry   T ,   aet.  36.      No  cough,    no   haemoptysis,    night 

sweats  +  :  dyspnoea  +  :  Signs  indefinite  :  Clinical  diagnosis, 
tubercle?  :  wife  has  pulmonary  tubercle.  Radiogram  :  slight 
pleural  adhesions  in  left  axillary  line  :  thickenings  at  left  apex  : 
left  chest  contracted  :  no  signs  of  pulmonary  involvement. 


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Radiography  of  the  Chest 


103 


2.  Sidney  P ,  act.  29.  Cough,  dyspnoea,  night  sweats,  haemo- 
ptysis a  staining  :  finger  nails  incurved  :  t°  gy-gS'^^.  Si^iis  :  in- 
definite, no  moist  sounds.  Radiological :  right  leaflet  of  diaphragm 
sluggish  :  a  visceral  pleuritic  shadow  running  parallel  to  diaphragm 
is  revealed  in  radiogram  taken  in  deep  inspiration  :  slight  pleuritic 
general  thickening  over  right  lung  :  a  few  scattered  foci  in  pul- 
monary fields  :  central  microcardia. 


I.  Alfred  W- 


—Bronchitic  and  Bronchiedatic 

,  was  in  sanatorium,  1912,  for  fifteen  weeks, 
then  said  to  have  bacillary  sputum  :  no  haemoptysis.  Signs :  on 
left,  percussion  note  impaired  at  apex,  a  few  moist  sounds,  heart 
apex  more  to  left  than  usual.  Clinical  diagnosis  :  fibrosis  of  left 
hing.  Radiogram  :  diffuse  cylindrical  bronchiectasis  in  both  lungs 
only  :  (non-tuberculous  ?). 


Diagram  7. 


2.  Edward   W ,  a,"t.  45,  carpenter.     Bronchitis  three  years 

:igo,  never  free  since:  cough,  expectoration,  no  ha_-moptysis  :  night 
sweating  :  effort  dyspnoea  :  no  emaciation  :  no  clubbing  :  Tbc. — : 
Clinical  :  percussion  note  impaired  right  apex,  distant  rhonchi.and 
a  few  post-tussive  crepitations  right  apex  posteriorly  (Diagram  7). 
Rndiogrant  85  :  patch  of  aggregated  foci  at  right  apex  with  an  area 
of  dilated  bronchi  surrounding  it  :  slight  emphysema:  microcardia 
and  cardioptosis.     (Broncliitis  tuberculosa.) 

3.  Elizabeth  C ,  aet.38.     Pleurisy  as  a  child,  bronchitis  every 

winter  since  :  pneumonia  eight  years  ago  :  dulness  both  apices  and 
crepitations  (12.6.18)  :  moist  sounds  gone  (30.7.18).  Clinical 
tliagnosis:  plithisis  Iioth  :ipices.  Radioi^rani:  shows  a  saccular  para- 
cardiac broncliicctasis  of  leftside  :  streaky  fields  :  calcification  first 
rib  cartilages.     (Non-tuberculous  bronchiectasis.) 


104  Radiography  of  the  Chest 

4.  Fanny  S ,   cet.  26.     Cough,  sputum,  emaciation,  pyrexia, 

lassitude,  no  hzemoptysis,  family  history — .  Clinical  (Diagram  S)  : 
scattered  rhonchi,  granular  breath  sounds  near  right  nipple.  Radio- 
gram 86 :  small  fibrocaseous  consolidation  near  right  nipple  (arrows) : 
scattered  foci  in  right  middle  lobe  and  in  left  lung :  some  generalised 
dilatation  of  bronchi :  paralytic  thorax,  slight  basal  emphysema : 
central  microcardia  slightly  dilated  :  thin  right  paratracheal  shadow 
(B.  tuberculosa). 

Diagram  8. 


Mrs.  S — — .    Diffuse  rhonchi ;  g.b.,  area  of  granular  breath  sounds 


5.  Henry  H ,  vet.  24.    Has  complained  of  cough,  with  copious 

expectoration  and  frequent  hremoptyses  since  an  attack  of  pneumonia 
six  years  ago :  no  loss  of  weight :  Tbc.  — :  is  following  the  vocation 
of  milk  carrier.  Signs :  no  crepitations,  diminished  movement  of 
right  side  with  emphysema.  Radiological :  diaphragmatic  halves 
almost  immobile.  Radiogram  shows  a  condition  of  dilated  cylin- 
drical and  saccular  bronchiectasis :  some  tubes  in  upper  left  lobe 
are  partially  filled  with  sputum  :  at  the  base  of  right  hilum  a 
triangular  patch  of  unresolved  pneumonia  ?  Rad.  diagnosis :  non- 
tuberculous  diffuse  bronchiectasis  after  bronchopneumonia. 
(Radiogram  87.) 

6.  AdaR ,  ast.  41.  Cough,  expectoration  somewhat  excessive, 

mucopurulent.  Signs  of  tubercle  inconclusive  :  Tbc.  — .  Radiogram 
88  shows  a  condition  of  purulent  bronchitis  (chronic  influenza)  with 
enlarged  hila  (sputum),  distribution  of  larger  tubes  well  seen :  the 
rounded  foci  in  periphery  are  tubes  cut  transversely,  filled  with 
secretion  :  note  the  bend  of  tube  (arrow)  just  below  sternal  end  of 
first  rib :  cardiac  opacity  normal.  No  radiological  signs  of  pul- 
monary tuberculosis.     (Bronchitis  chronica  mucopurulenta.) 

7.  John  H ,  3et.  27.     Haemoptysis,  twelve  times  in  a  month  : 

gassed  three  years  ago  (tear  gas) :  cough,  sputum  :  Tbc.  — :  no 
physical  signs  in  lung.     Radiogram  :  both  fields  filled  with  an  in- 


cy 


Facing  p.  104. 


Radiography  of  the  Chest  105 

tense  interlacing  fibrosis,  especially  marked  at  both  bases :  a  few 
■calcareous  nodes  in  right  hilum  (non-tuberculous  bronchial  fibrosis). 

A  discussion  of  the  relations  between  bronchial  asthma 
and  tubercle  must  be  relinquished  for  the  present. 

H. — Partial  Miliary  Dissemination 

I.  Eleanor  O ,  aet.  22.  In-patient,  then  in  sanatorium  five  years 

ago :  no  cough,  no  sputum,  no  haemoptysis.  Signs :  movement  at 
right  apex  diminished  and  expiration  prolonged.  Is  at  work,  but 
feels  very  tired  and  languid  :  t98'4°-99-6o.  Radiogram  shows  old 
healed  (?)  infiltration  at  right  supraclavicular  apex  :  and  a  shower  of 
very  small  foci  in  the  right  axilla,  apparently  more  recent  (minimal 
activity  with  slight  pyrexia  and  lassitude  ?) :  central  microcardia : 
emphysema. 

K. — Exophthalmic  Goitre 

1.  Sylvia  E ,  xt.   20.     Enlarged  thyroid,   cough  night  and 

morning:  expectoration:  sweating  sometimes:  at  right  apex  per- 
cussion note  impaired  :  expiration  prolonged,  rhonchi  right  base. 
Radiogram:  right  paratracheal  opacity:  opacities  outside  right 
hilum  :  irregular  right  phrenic  leatlet,  supraclavicular  apices  clear  : 
dilated  right  auricle. 

2.  Sarah  M ,  aet.  23,  cigarette  maker.     Cough  three  weeks, 

expectoration  copious  :  slight  swelling  of  thyroid,  slight  exophthal- 
mos and  tremor  of  hands:  crepitations  at  left  hilum  posteriorly: 
systolic  hoemic  murmur.  Radiogram  :  considerable  perihilar  dis- 
semination, especially  on  left,  and  enlarged  paratracheal  glands. 

The  relations  between  tubercle  and  Graves'  disease  are 
still  obscure.  Radiological  examination  in  191  5  and  1916 
of  twenty  cases  in  young  women  sent  up  for  X-ray  treat- 
ment showed  paratracheal  opacities  as  a  general  rule, 
increased  hilar  opacities,  and  occasionally  the  signs  of  a 
massive  general  infection.  When  the  salient  features  of 
the  disease,  as  the  exophthalmos,  the  tremor,  and  cervical 
swelling  are  less  obvious,  certain  symptoms,  as  the  cough, 
occasional  bursts  of  perspiration  (which  are,  however, 
diurnal),  the  oscillations  of  temperature,  the  dyspnoea, 
tachycardia,  emaciation,  may  suggest  incipient  phthisis. 
Moreover,  in  many  cases  of  chronic  phthisis,  a  recru- 
descence of  the  disease  may  be  accompanied  by  a  fresh 
outburst  of  adrenalism.  Possibly  certain  facts  to  be 
obtained  from  the  radiogram  may  be  useful  in  prognosis. 
With  regard   to   the   opposite  condition  of  myxoedema,  in 


io6       «  Radiography  of  the  Chest 

which  it  is  said  the  resistance  to  tubercle  is  diminished^ 
the  author  has  little  experience.  In  one  case  of  chronic 
myxcedema  after  middle  age,  the  radiogram  showed  both 
lungs  filled  with  small  disseminated  fibroid  foci,  with  a 
hilar  infiltration  at  junction  of  right  interlobe  with  sternum, 
and  a  cardiac  ^opacity  in  which  the  pulmonary  curve  was 
markedly  enlarged. 

L. — Nasal  Lesions 

I.   Albert  E ,   ast.  29.     Cough,  loss    of   voice,    emaciation, 

pharyngitis,  deflected  septum,  chronic  rhinitis,  rhonchi  in  chest. 
Radiogram  ;  right  supraclavicular  apex  dull :  in  left  chest  a  few 
old  opacities :  no  signs  of  active  tuberculous  disease.  Obviously 
the  cause  of  the  cough  and  slight  emaciation  is  the  chronic  rhinitis 
with  pharyngitis,  and  the  gradual  downward  involvement  of  the 
larynx  and  larger  bronchi. 

hicipicjit  Pulmonary  Tuberculosis. — In  cases  which  are 
diagnosed  clinically,  incipient  or  early,  radiological  ex- 
amination often  reveals  the  existence  of  one  or  more 
indurated)  even  calcareous  arrested  lesions  either  in  the 
apex,  or  in  the  hilum  and  its  vicinity.  The  clinical  signs 
are  really  due  to  the  resuscitation  of  a  dormant  lesion  or 
to  the  incidence  of  a  new  infection — usually  the  former. 
On  the  other  hand,  when  the  disease  is  really  incipient, 
the  radiological  manifestations  may  be  meagre  and  in- 
different. But  such  an  event  is  really  unique ;  as  a  rule  a 
lesion  which  is  incipient  to  the  clinician  is  already  pro- 
gressive to  the  radiologist.  There  are  three  principal 
localities  in  which  radiology  may  find  the  first  signs  of 
pulmonary  tubercle,  viz.,  (i)  the  supraclavicular  apex, 
(2)  the  hilum,  and  (3)  the  paravertebral  triangle. 

(i)  T/ie  supraclavicular  apex  or  apical  triangle.  In  order 
to  delineate  clearly  doubtful  lesions  in  this  area,  it  is 
advisable  to  take  special  plates  of  the  posterior  apices, 
stereoscopic  by  preference.  The  X-ray  tube  should  be 
soft,  and  slightly  elevated  towards  the  head,  so  as  to  throw 
the  clavicles  downwards,  and  to  give  an  unobstructed 
view  of  the  second  and  third  posterior  interspaces. 
Opacities  present  in  this  situation  may  be  produced  by 
old    arrested  fibroid   lesions,  probably   containing  smal 


00 
2ci 


Tacing'p.  I06. 


Radiography  of  the  Chest  107 

cavities,  of  the  size  of  a  pea  and  of  the  shape  of  a  clover- 
leaf;  by  calcareous,  caseating  or  fibroid  nodular  lesions ;. 
by  diffuse  or  irregular  pleuritic  thickenings  and  small 
calcareous  pleural  plates,  often  linear  and  13'ing  horizon- 
tally. They  may  be  due  to  opacities  lying  externally  ta 
the  pleura,  such  as  accumulations  of  adipose  tissue,  or 
thickened  subcutaneous  or  muscular  tissue,  to  sclerodermia 
or  indurated  and  calcareous  lymphatic  glands  lying  in  the 
supraclavicular  fossa.  Stereoscopic  radiograms  place  each 
opacity  at  its  proper  level,  and  recognise  the  presence  ot 
slight  scoliosis.  In  most  cases  the  foci  are  arrested  and 
of  no  serious  importance. 

Recent  apical  lesions  are  seldom  susceptible  of  verific- 
ation by  autopsy.  Radiogram  89  shows  several  foci^ 
about  pin-head  size,  in  each  second  interspace.  The  general 
transparency  is  not  affected.  On  the  right  they  are  rather 
more  numerous ;  on  the  left  they  are  somewhat  larger  and 
more  distinct.  Post-mortem :  in  both  spaces  several 
caseous  foci  were  found,  on  the  left  some  were  indurated 
and  larger.     Apical  pleura  on  each  side  intact. 

(2)  The  Jiiliim. — In  the  great  majority  of  cases  pulmonary 
tubercle  appears  to  take  its  origin  from  the  central  glands. 
These  have  been  described  in  Chapter  II.  Disease  in  this 
situation  leads  to  an  irregular  configuration  of  the  hilar 
opacities,  often  the  right  alone,  and  to  an  increase  in 
breadth.  If  merely  hypertrophied  there  may  be  only  a 
faint  gre3'ish  increase  of  shadow;  distinct  rounded  shadows 
within  the  hilum  may  be  caseating,  fibroid  (anthracotic)^ 
or  calcareous  glands  according  to  the  degree  of  opacity. 
Caseating  paratracheal  glands  appear  as  convex  opacities 
in  the  two  anterior  interspaces,  or  as  an  opacity  parallel  to 
the  sternum.  When  the  area  between  the  right  hilum 
and  cardiac  opacit}',  which  is  usually  translucent,  becomes 
opaque,  the  latter  is  often  due  to  caseating  bifurcation 
glands  on  the  lower  border  of  the  right  extrapulmonary 
bronchus.  With  regard  to  the  hilum  itself,  care  must  be 
taken  not  to   diagnose  tubercle   because  of  an  increased 


To8  Radiography  of  the  Chest 

shadowing  of  the  hilum  only,  since  this  may  occur  in 
association  with  pneumonia,  bronchopneumonia,  influenza, 
pertussis,  and  measles;  also  in  simple  chronic  bronchitis, 
aneurysm  of  the  aorta,  and  in  passive  pulmonary  congestion 
from  morbus  cordis  ;  it  may  be  due  to  the  inhalation  of 
dust,  so  that  oppidans  do  not  exhibit  normal  hila,  and  par- 
ticularly those  who  work  habitually  in  a  dust-laden 
atmosphere  (pneumoconiosis) ;  in  children  under  fifteen, 
since  anthracosis  do  not  occur  before  that  age,  heavy  hilar 
opacities  are  to  be  viewed  with  suspicion  unless  there  are 
other  positive  circumstances  to  account  for  them.  In  the 
description  of  certain  radiograms  already  given  the 
diagnosis  of  hilar  phthisis  has  been  discussed,  so  that 
further  remarks  are  here  superfluous. 

(3)  The  Paravertebral  Triangle  [enclosed  by 
lines  drawn  {a)  from  the  right  hilum  about  the  level 
of  the  vertebral  end  of  the  seventh  rib  to  a  point 
in  the  clavicle  half  way  between  its  sternal  end  and 
the  axillary  margin  of  the  chest;  {h)  along  the  media- 
stinum; and  (c)  along  the  inner  clavicle]  frequently 
contains  cord-like  linear  opacities  which  are  often  studded 
with  minute  foci.  Into  the  outer  and  upper  part  of  the 
triangle  the  anterior  end  of  the  first  rib  usually  pro- 
trudes ;  and  it  is  in  this  vicinity  that  actual  consolidations 
and  aggregations  of  foci,  in  the  first  place,  generally 
materialise,  that  is,  within  the  distribution  of  the  para- 
vertebral bronchus.  In  some  instances  autopsy  has 
shown  that  these  paravertebral  linear  opacities  are 
produced  by  fibrotic  thickening  of  the  lymphatics  ;  in 
•others  the  radiograms  suggest  bronchial  dilatations  with 
thickened  walls,  which  appear  invested  with  small  round 
foci,  generally  considered  peribronchial  from  their  position ; 
in  some  the  leash  of  shadows  suggests  the  presence  of 
congested  vessels  and  lymphatics.  The  latter  may  be 
found  in  congestive  forms,  and  then  often  lie  more  external 
between  the  right  upper  interlobe  and  the  axilla,  and  are 
accompanied  by  small  frequent  haemoptyses.     When  the 


Radiography  of  the  Chest  109 

disease  slowly  disseminates,  in  all  directions  along  the 
lymphatics  it  is  usually  benign,  and  the  small  foci  become 
in  time  fibroid  and  harmless  (follicular).  Nodal,  even 
larger  infiltrations  may  be  found  in  early  cases  in  the  para- 
vertebral triangle,  in  the  upper  external  part  already  men- 
tioned, or  at  the  periphery  of  the  hilum  and  in  the  perihilum 
just  outside  it.  The  diagnosis  between  the  two  forms, 
follicular  and  infiltrative,  may  generall}^  be  made  from  the 
radiogram,  particularly  if  assisted  by  a  correct  report  of 
clinical  symptoms  and  signs.  In  man}-  cases  of  early 
tubercle  apical  and  hilar  disease  are  both  present,  but  hilar 
changes,  without  apical,  are  more  common  than  the 
converse. 

Less  favourite  situations  for  the  incipient  development 
of  nodules  and  infiltrations  are  the  deep  axilla  and  the 
vicinity  of  the  interlobes.  Considering  the  number  of  the 
latter  type  the  radiologist  meets,  so  to  speak,  incidentally, 
it  is  probably  not  at  all  infrequent. 

To  sum  up. — The  majority  of  incipient  cases  (60  per  cent, 
at  least)  exhibit  either  minute  foci  dVth  in.  in  diameter,  or 
rather  more)  or  minimal  infiltrations,  either  in  the  upper 
lobe  (that  is,  within  the  supraclavicular  triangle,  or  imme- 
diately below  the  inner  third  of  the  clavicle),  or  just  outside 
the  limits  of  the  hilum — in  some  instances  in  both  situations 
simultaneously.  These  areas  lie  within  the  distribution  of 
the  paravertebral  bronchus.* 

With  regard  to  central  lesions,  a  caseating  right  hilum, 
apparently  quiescent,  may  re-awaken,  inducing  cough, 
wasting,  and  night  sweats  ;  sometimes  only  emaciation 
and  a  stained  sputum.  The  author  has  met  with  cases 
where  a  diagnosis  of  "  tuberculosis  of  the  roots  "  has  been 
made  by  the  physician,  where  only  cough  and  emaciation 

•  The  foci  may  become  aggregated  and  form  small  patches  of  broncho- 
pneumonic  infiltration.  If  the  opacities  are  of  feeble  intensity,  with 
ill-defined  and  fluffy  margins,  they  are  iicUvc,  with  clinical  symptoms  and 
physical  signs;  whereas  darker  shadows  with  sharper  edges  indicate 
caseation,  fibro-caseation,  or  fibrosis. 


no  Radiography  of  the  Chest 

without  any  physical  signs  have  been  present,  and  in-which 
radiology  revealed  increased  hilar  opacities  merely.  Hilar, 
or  perihilar,  phthisis  should  not  be  diagnosed  unless  a 
definite  amount  of  pulmonary  infiltration  can  be  de- 
monstrated by  the  radiologist,  and  then  only  in  correlation 
with  the  signs  and  symptoms. 

In  very  young  children  (under  one  year)  the  researches  of 
Ribadeau-Dumas,  Weil  and  Maingot  (191 2)  have  shown 
that  tubercle  usually  begins  as  a  small  focus  in  the  lower 
lobe,  from  which  it  spreads  centripetally  to  the  hilum,  and 
then  affects  the  paratracheal  and  bifurcation  glands  before 
reaching  the  apices.  These  researches  do  not  seem  to 
have  been  confirmed  up  to  the  present,  although  the  patho- 
logical observations  of  Ghon  (191 3)  prove  that  in  children 
such  primary  foci  may  occur  in  any  part  of  the  lung.  In 
/a/^r  )'(?<7r5  (5-15)  pulmonary  tubercle  is  largely  a  question 
of  central  glandular  disease  and  its  centrifugal  diffusion 
along  the  lymphatic  tracts.  At  this  period  children 
appear,  however,  to  possess  a  remarkable  power  of  control 
over  the  further  development  of  this  disease,  a  fact  pro- 
bably due  to  the  production  of  immunity  by  the  primary 
infection.  Tuberculous  infection  may  be  slight,  moderate, 
or  massive,  and  its  degree  is  associated  with  altered 
radiographical  signs  of  lymphatic  dissemination.  The 
types  of  tubercle  in  children  are,  (a)  caseating  lymphatic 
intrathoracic  glands ;  ih)  hilar  infiltrations  chiefly  on  right 
and  affecting  one  of  the  upper  two  lobes;  (c)  broncho- 
pneumonic  nodular  disease  due  to  irruption  from  the  hilum 
into  the  bronchial  tree ;  id)  fibroid  disease  of  axillary  or 
apical  areas,  sometimes  associated  with  pressure  on  root 
bronchi  by  enlarged  packets  of  hilar  glands ;  {e)  broncho- 
pneumonic  pseudo-lobar  disease  springing  from  the  hilum  ; 
(/)  very  occasionally  extensive  fibroid  cavitary  lesions ; 
(^)  miliary  and  submiliary  forms.  Children  are  often 
brought  to  the  radiologist,  or  sent  to  the  tuberculosis 
dispensary,  with  the  suspicion  or  the  diagnosis  of  phthisis, 
in  which   the  lesion  is  either  non-tuberculous  or  a  non- 


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Radiography  of  the  Chest  iii 

tuberculous  sequel,  as  it  were,  of  an  arrested  perihilar 
tubercle.  In  the  majority  of  cases  it  is  either,  (i)  a  central 
glandular  disease  with  peripheral  dissemination,  which  is 
gradually  fading ;  (2)  one  of  the  manifestations  of  un- 
resolved bronchopneumonia  (cirrhosis),  in  the  latter  case 
often  implicating  the  right  base  and  right  cardiophrenic 
cul-de-sac,  accompanied  by  cough,  wasting,  basal  crepita- 
tions and  inferior  emphysema ;  (3)  in  other  cases  there  is 
a  brcjic/iiecfasis,  diffuse  and  cylindrical,  or  more  or  less  local 
and  confined  to  the  hilum  and  the  base.  This  condition 
requires  a  different  form  of  treatment  from  that  of  hilar 
tubercle  ;  if  the  affection  does  not  clear  the  little  patient 
may  become  a  chronic  bronchitic,  although  the  character- 
istic sputum  of  bronchiectasis  may  never  or  may  take  years 
to  develop.     {Vide  Vol.  II.) 

The  Radiological  Signs  of  Arrested  and  Healed  Phthisis 
These  may  be  seen  as  (i)  isolated  calcareous  nodes, 
which  may  be  as  dark  as  projectiles,  generally  rounded, 
sometimes  oblong,  and  present  within  the  hilum,  perihilum, 
paravertebral  triangle,  or  along  the  bronchi  running  towards 
the  right  middle  lobe  and  bases  of  both  lungs  ;  (2)  the 
inverted  comma  (Crane)  already  mentioned  ;  (3)  old  fibroid 
and  anthracotic  opacities  of  the  paratracheal,  and  in  the 
right  oblique  position  of  the  bifurcation  glands ;  (4)  uni- 
lateral fibroid  infiltrations  in  the  supraclavicular  and  upper 
part  of  the  subclavicular  triangle,  with  lighter  spaces  in 
their  midst  (old  cavities);  (5)  scattered  old  nodal  opacities 
which  have  diminished  in  size,  increased  in  densit}'',  and 
their  cloudy  irregular  borders  have  become  replaced  by 
sharp  clean-cut  edges  ;  (6)  occasionally  slight  deviations 
of  the  mediastinum  towards  old  fibroid  lesions;  (7)  old 
costal  adhesions  of  the  diaphragm,  or  cardiophrenic  resi- 
dues, and  pleuritic  thickenings  at  apex,  or  at  axillar\-  lines, 
with  diminution  of  interspaces  and  dove-tailing  of  the  ribs; 
(8)  a  scattered  diffuse  dissemination  of  small  foci  in  young 
children  and  adults  (tuberculous  infection),  due  to  13'm- 
phatic  dissemination ;  or  a  more  uniform  distribution  of 


112  Radiography  of  the  Chest 

small  rounded  fibroid  foci  as  the  result  of  bronchogenic 
diffusion  from  caseating  cavities  ;  and  (9)  shrinking  of  chest 
from  pleuritic  adhesions,  and  the  production  of  a  scoliosis 
convex  to  the  more  healthy  side.  In  the  two  latter 
divisions  some  may  be  cases  of  feebly  progressive  fibroid 
disease  ;  (10)  occasionally  in  the  adolescent  one  may  localise, 
in  the  external  pulmonary  fields,  the  primary  focus  of 
Ghon. 

Associated  Disease 
It  has  been  stated  that  various  types  of  pleurisy,  with  or 
without  effusion,  of  chronic  bronchitis,  asthma,  cylindrical 
and  saccular  dilatations  of  the  bronchi  may  accompany 
tuberculosis.  Occasionally  pronounced  forms  of  morbus 
cordis,  prominent  dilatations  of  the  aorta,  and  conspicuous 
aneurysms  may  be  associated  with  it. 

Arthur  H ,  aet.  39,  ex-marine  policeman  :  washed 

down  hatchway  in  December,  191 5,  kept  on  duty  three 
months,  then  entered  hospital  with  pain  in  right  chest 
and  dyspnoea.  Cough  commenced  October,  1917,  and 
emaciation  became  severe  (three  stone  in  four  months)  : 
Tbc.  +  :  haemoptysis,  occasional  streaks.  Clinical  sigjis  : 
dulness  right  chest,  bronchial  breathing,  short  systolic 
at  base :  dyspnoea  extreme :  pupils  and  radial  pulses 
equal:  no  tracheal  tugging:  liver  enlarged,  distended 
veins  over  abdomen:  fingers  clubbed  and  cyanosed. 
Radiogram  90 :  cardiac  opacity  much  enlarged  towards 
right,  dulness  in  right  upper  lobe  with  small  excavations. 
The  opacity  was  considered  to  be  an  aneurysm  of  the 
first  part  of  the  aorta.  It  possessed  no  pulsation,  and  it 
moved  slightly  with  inspiration.  The  opacity  became 
larger  very  gradually,  finally  marked  pulsation  became 
visible  over  the  right  mamma.  The  autopsy  proved  the 
existence  of  an  aneurysm  of  the  ascending  aorta  which 
had  eroded  several  of  the  anterior  ribs,  with  tuberculosis 
of  the  right  upper  lobe. 

So  much  time  has  been  devoted  to  the  different  types  of 
phthisis  that  an  account  of  the  relations  between  this 
disease  and  syphilis,  malaria,  traumatism,  and  carcinoma 
must  be  unavoidably  postponed. 


Radiography  of  the  Chest  1 13 

The  Heart  in  Pulmonary  Tuberculosis 
This  question  in  reality  deserves  a  chapter  to  itself;  we 
must  content  ourselves  with  a  few  disjointed  remarks  on 
the  subject.  Radiograms  17,  24,  25,  27A,  27B,  33,  35,  38, 
46,  51,  55,  57,  61,  62A,  6-/,  70A,  71  and  91  will  demonstrate 
the  prevalence  of  microcardia  in  pulmonary  phthisis,  and 
also  that  this  form  of  heart  is  not  necessaril}'  limited  to 
any  one  particular  type  of  phthisis.  No  doubt  its  character 
is  one  of  the  causes  of  the  low  arterial  tension,  of  the 
tachycardia,  and  of  the  proneness  to  dilate  under  conditions 
of  severe  strain  which  is  exhibited,  among  others,  b}' 
cases  of  disordered  action  of  the  heart  in  soldiers.  It 
is  frequent!}^  placed  centrally  in  the  chest,  occasionally 
laterally  (Radiogram  91).  It  is  obvious  that  the  prognosis 
in  tubercle,  as  regards  length  of  life,  is  dependent,  cceteris 
paribus,  on  the  degree  of  microcardia,  the  integrity  of  the 
aorta,  their  dilatability,  and  the  extent  of  the  muscular 
reserve.  Moreover,  cardiophrenic  adhesions  may  be 
present,  which  render  the  prospect  still  more  unfavourable. 
IVith  regard  to  Diagnosis,  the  Association  of  Microcardia 
iVith  Haemoptysis  is  always  Suspicious.  Theorthodiagraphic 
transverse  measurement  may  be  as  low  as  three  inches 
but  the  chief  point  appears  to  be  the  differentiation 
between  a  normal  cardiac  silhouette  and  one  of  micro- 
cardia disfigured  and  magnified  by  dilatation.  [The 
author  has  met  with  several  cases  of  centrally  placed  hearts 
in  late  middle-aged  men,  who  have  exposed  themselves 
continuously  to  increased  bodily  and  mental  strain  during 
the  war  ;  in  such  individuals  there  has  been  considerable 
cardiac  dilatation,  fits  of  giddiness,  sudden  faints,  slight 
neurasthenia,  and  occasionally  a  low  arterial  tension. 
Rest  in  bed  for  some  weeks,  the  exhibition  of  digitalis,  and 
gentle  massage  are  required.] 

The  relation  of  microcardia  to  general  congenital 
asthenia,  including  visceroptosis,  and  in  particular  to  its 
variety  the  habitus  phthisicus,  appears  to  be  intimate. 
Roughly,  the  types  of  microcardia  may  be  grouped  under 


114 


Radiography  of  the  Chest 


three  headings,  (i)  microcardia  without  cardioptosis ; 
(2)  with  cardioptosis  ;  (3)  the  "  hanging"  heart.  (Diagram 
9.)  In  the  last  group  there  is  a  space  on  deep  inspiration 
between  the  heart  and  diaphragm,  better  seen  in  the 
upright  position,  during  which  the  right  ventricle  barely 
touches  the  central  tendon.  In  this  case  the  suspensory 
ligaments  (vessels,  upper  pericardial  and  cervical  fascia) 
hold  firm.*  In  some  cases  with  marked  ptosis  of  the 
diaphragm  (Radiogram  91)  the  cardiac  apex  is  at  the  level 

Diagram  9. 


Hanging  heart  in  woman  aged  28  years.with  bronchial  asthma  and  tubercle 

suspect;  ptosis  of  diaphragm.     Ao,  left  aortic  bulge;  P.,  pulmonary  curve; 

AS.,   left   auricle;    P.e.,  pericardium  visible   in   left  cardiophrenic  sulcus. 

Radiogram  taken  in  deep  inspiration. 

of  the  eleventh  rib  in  recumbency.  In  this  radiogram 
there  is  evidence  of  old  arrested  tubercle  in  the  upper 
lobes,  and  severe  gastroptosis  was  shown  by  the  bismuth 
meal.  On  the  screen  the  right  ventricle  may  take  part  in 
the  right  vertical  border  of  the  cardiac  opacity,  and  the 
right   auricle   may   be   above   and    behind    it.     Occasion- 

*  The  three  variations  may  be  expressed  thus:  (I)  M  —  C  —  V;  (2) 
M  +  C  +  V;  (3)  M  +  C<  +  V>;  where  M= microcardia;  C= cardioptosis; 
and    V  =  visceroptosis. 


Radiography  of  the  Chest  115 

ally  the  hanging  heart  (cor  pendulum)  is  said  to  produce 
tracheal  tugging  by  traction  on  its  suspensory  attachments. 
The  depth  of  the  left  ventricle,  and  the  degree  of  its  hyper- 
trophy, if  any,  may  be  determined  by  Vaquez-Bordet's 
method  of  procedure. 

Concluding  Remarks 

The  advantages  of  the  X-ray  investigation  have  been 
amply  demonstrated  in  the  preceding  pages.  But  it  should 
not  be  expected  that  the  radiologist  is  able  to  determine 
at  one  examination  the  diagnosis  in  cases  which  have 
possibly  puzzled  one  or  more  skilled  clinicians.  Two,  even 
more,  examinations  may  be  nece,ssary,  and  supplementary 
plates,  ordinary  and  stereoscopic,  of  suspicious  areas  may 
be  expedient.  Progressive  tendency  and  activity  in  the 
absence  of  definite  clinical  symptoms  may  be  ascertained 
by  observations  at  fortnightly  intervals  if  required. 
Certain  signs  are  special  to  the  radiologist:  the  progressive 
studding  of  the  bronchi  in  slow  perihilar  dissemination, 
the  hazy  outlines  of  an  apical  active  infiltration,  the  wedge 
of  dilated  vessels  or  lymphatics,  with  its  apex  at  the  hilum, 
inmanycongestivecases:  thesmall  nodular  foci  in  the  supra- 
clavicular and  paravertebral  triangles,  the  unexpected  diffu- 
sion of  nodular  foci  from  half-emptied  cavities,  the  fusiform 
scraps  and  cylindrical  fragments  producing  a  broken  chain 
from  the  hilum  to  the  clavicle  and  axilla  in  forms  passing 
into  arrest  and  fibrosis,  the  circumscribed  sharp  edges  of 
calcareous  foci  and  of  healed  arrested  fibroid  patches,  and 
the  caseating  opacities  of  the  central  lymphatic  glands. 
These  are  phenomena  which  the  radiologist  must  learn  to 
recognise,  and  at  the  same  time  assign  to  each  its  proper 
importance  and  interpretation.  As  regards  the  rest,  the 
mutual  co-operation  of  clinician,  pathologist,  and  radiologist 
is  requisite  in  order  to  increase  our  knowledge  of  the 
disease  in  its  incipient  stages,  its  principal  types,  the  life 
history  of  each,  and  to  mature  the  methods  of  treatment 
and  control. 


ii6  Radiography  of  the  Chest 

PERIODICALS  AND    BOOKS   OF    REFERENCE. 

1.  Norris  and  Landois.    "  Diseases  of  the  Chest,"  1917. 

2.  Walsham  and  Orton.    "  The  Radiology  of  the  Chest,"  1906. 

3.  Greene.    "  Medical  Diagnosis."     IV.  Edition,  1918. 

4.  Piery.    "  La  Tuberculose  Pulmonaire,"  igio. 

5.  Chantemesse  et  Courcoux.    "Les  Pleuresies  Tuberculeuses,"  1913. 

6.  Rieder.    "Die  Rontgendiagnostik  der  Lungen,"  1912. 

7.  Letulle.    "La  Tuberculose  Pleuropulmonaire,"  1917. 

8.  Assmann.    "  Erfahrungen  ii.  d.   Rontgenuntersuchungen    der  Lungen,'* 

1914. 

9.  Dunham.    "Stereorontgenography  of  the  Chest,"  1915. 

10.  Riviere.    "The  Diagnosis  of  Early  Tubercle,"  1919. 

11.  Barjon.     "  Radiodiagnostic  des  Affections  Pleuropulmonaires,"  1916. 

12.  Dickey.    "Applied  Anatomy  of  the  Lungs  and  Pleura,"  1911. 

13.  Fowler.     "Chronic  Arrested  Tuberculosis,"  1892. 

14.  Poncet  et  Leriche.     "La  Tuberculose  Inflammatoire,"  191 2. 
15-  Poncet  et  Leriche.    "  Le  Rheumatisme  Tuberculeux,"  1909. 

16.  Bard.     "Formes  Cliniques  de  la  Tuberculose  Pulmonaire,"  1901. 

17.  Ewart.     British  Medical  Journal,  October,  1912. 

18.  Pegurier.    Congr.  Internat.,  Madrid,  1903. 

19.  F.  Bezanfon.    Soc.  Med.  des  Hop.,  1907-1908. 

20.  Chauvet.     La  Presse  Medicate,  1908. 

21.  Neumann  and  Matson.    Beilr.  z.  Klitiik  der  Tub,  191 2. 

22.  Straub  and  Otten.    Beitr  z.  Ktiuik  der  Tub,  igii. 

23.  Groedel.    "  Rontgendiagnostik,"  1909. 

24.  A.  Bezangon.      "Conformations  thoraciques    chez    les  Tuberculeux.'" 

These.    Paris,  1906. 

25.  Crane.    American  Journal  of  Rontgenology,  I918. 

26.  Morton  and  Owen.     Archives  0/ Radiology,  igi^. 

27.  Schut.     Beitr.z.Klitiik  der  Tub,  igi^. 

28.  Jordan.     Practitioner,  1912. 

29.  Heise  and  Sampson.     American  Journal  0/  Tuberculosis,  1917. 

30.  Frankel.    Miinch  Med.  Woch,  August,  1916. 

31.  Walsham  and  Overend.     Archives  of  Radiology ,  August,  I9I5- 

32.  Overend  and  Riviere.     Archives  of  Radiology,  August,  1916,  and  Lancel„ 

September,  1916. 

33.  Beclere.     "The  Diagnosis  of  Tubercle,"  etc.,  1904. 

34.  Riviere.    "  Hilus  Tb.  in  the  Adult,"  February,  1919.    (Lavcet.) 

35.  Hulst.     American  Journal  of  Rontgenology,  October,  1916. 

36.  Overend  and  Hebert.    Atchives  of  Radiology, 'Dzcevaber,  igij. 

37.  Caccini.     Medical  Record,  1918. 

38.  American  Journal  of  Tuberculosis,  1917,  1918,  1919.     (Various  papers.> 

39.  Knox.    Treatise  on  Radiography  and  Radio-therapeutics  (1914). 

40.  Morriston  Davies.    Surgery  of  the  Lung  and  Pleura  C1919). 


INDEX 


Abortive  phthisis  (Bard),  48 
Adhesions,  apical,  81 

basal,  81 

interlobar,  79 

mediastinal,  81 

phrenic,  81 
Age,  influence  of,  on  tuberculosis,  19 
Alcohol  and  tubercle,  37 
Anasmia  in  tuberculosis,  30,  100 
Aneurism  and  phthisis,  18,  30,  112 
Anthracosis,  65 
Aortic  bulge,  left,  3 
Apical  nodular  phthisis,  49 

infiltrative  phthisis,  50 
Appendix,  left  auricular,  6 
Arrested  tubercle,  X-ray  signs  of.  If  I 
Aspiration  from  cavities,  33,  35 
Asthma,  59 

B 

Bard,  classification  of,  20 
Becl^re,  fibroid  phthisis,  58 
Bifurcation  glands,  23,  28 
Blood  pressure  in  phthisis,  30 
Botalli  ductus,  pulsation  of,  7 
Breath  sounds,  94 
Breathing,  granular,  94,  96 
Bronchial  glands,  anatomy  and  tuber- 
culosis of,  21,  tt  »cq. 
phthisis,  20 
Bronchiectasia,  cylindrical,  3 1 
Bronchiectasis  and    tubercle,    65,   67, 

90,91 
Bronchiectatic  fold  or  triangle,  3 1 
Bronchitis  and  tubercle,  56,  103 
fibrinous,  3r 
muco-purulenta,  104 
Broncho-pneumonia,  influenzal,  39 
tuberculosa,  acute  (galloping),  42 
chronic,  43 

nodal  (disseminated),  37 
nodular  (disseminated),  33 
pseudolobar,  41,  45 
subacute,  44 


Carcinoma  of  lung,  71 
Carcinomatosis,  74 
Cardioptosis,  55,  II3 


Cavities,  89,  100 

and  pneumothorax,  90 
Chest,  contracted,  47,  51 

emphysematous,  16,  86 

long,  flat,  47,  51 

normal,  I 

paralytic,  47,  51 
Children,  tuberculosis  in,  22,  no 
Cirrhosis  of  lung,  58 
Classification  of  pulmonary  tubercle,  18 

Bard,  20 

Frankel,  21 

Nicol,  21 

Turban,  20 
Closed  cases,  21,  49,  92 
Coal  miner's  phthisis,  65 
Congestion,  passive,  of  lung,  1 3 
Conjugal  phthisis,  5 1 
Contact  cases,  6 1 
Cor  pendulum,  1 1 3,  1 14 
Crane's  inverted  comma,  36,  64,  et  scq. 
Creeping  pneumonia,  1 5 
Crepitant  rales,  94,  95 
Cuneate  interlobar  shadows,  54 

D 

Dextro-cardia,  66 

Diabetes  and  phthisis,  19,  33 

Diaphragm,  14 

crural,  14 

dome  of,  15 

in  decubitus,  15,  16 

sterno-costal,  14 
Diagnosis,  X-ray,  in  phthisis,  92 
Dilatation  of  aorta  in  chronic  fibrosis, 

76 
Disseminated  phthisis,  33,  lOI 
Dissemination,  lymphatic,  30,  56 

partial  miliary,  105 
Ductus  Botalli,  7 
Dulness,  parasternal,  25 

paravertebral,  25 
Dyscrasias,  [9 
Dysphagia  in  phthisis,  38 


Emphysema,  85 

annular,  27,  47,  87 
after  gassing,  86 
compensatory,  85 
hypertrophic,  86 


ii8 


Index 


Emphysema,  perihilar,  86 

radiology  of,  86 
Evidence,  positive,  97 

presumptive,  97 
Ewart,  paravertebral  dulness,  25 
Exophthalmic  goitre  and  tubercle,  27, 
55,  105 


Fibrinous  bronchitis,  31 

Fibrocaseous  phthisis,  20 

Fibroid  induration,  102 
phthisis,  58 

cavitary,  58,  59.  67 
diffuse  granular,  58,  59 
disseminated,  58,  59 
infiltrative,  58,  59,  60 
with  bronchiectasis,  67 

First  rib  cartilage,  calcification  of,  2 

Fissures  of  lung,  10 

Fowler's  line  of  march,  41 

Friction  sounds,  pleuritic,  95 

Q 

Galloping  phthisis,  42 
"  Gassed  "  lung  and  bronchitic  fibrosis, 
104 

and  emphysema,  87 
Glands,  bifurcation,  22 

hilar,  22 

tracheo-bronchial,  22 
Goitre,  endothoracic,  8 

exophthalmic  and  tubercle,  27,  55, 

105 
Granular  breathing,  94,  96,  104 

tuberculosis,  59 
Graves'    asphyxial    type    of    miliary 

phthisis,  75 
Gummata  of  lung,  62 

H 

Haemoptysis,  varieties  of,  88 
"Hanging"  heart,  114 
Healed  phthisis,  ill 
Heart,  outlines  of,  3 

hypoplasia  of,  55 

in  tubercle,  II3 

soldier's,  113 
Hilar  glands,  23 

lesions  of,  99 

irruption  of,  28 

radiography  of,  24 

phthisis,  51,  107,  et  scq. 
Hilum  of  lung,  3,  10,  23,  107 

I 

Incipient  phthisis,  1 06 


Influenza  and  tubercle,  33,  50 

and  broncho-pneumonia,  39 
Interlobar  phthisis,  44,  45,  lOO 


Kronig's  isthmus,  95 


Laennec's  grey  infiltration,  45 
Laryngeal  nerve,  recurrent,  51 
Latent  phthisis,  48 
Lung,  fibrosis  of,  58 

fissures  of,  10 

lobes  of,  10 
Lymphatic  glands,  bronchial,  23 

in  adults,  30 

in  children,  29 
Lymphocytosis  in  active  tubercle,  27 

in  arrested  tubercle,  26 

M 

Mammary  gland,  17 
Mediastinitis,  26,  27 
Mediastinum,  displacement  of,  58 

glands  of,  23 
Meningitis  tuberculosa,  74 
Metallic  tinkle  in  pneumothorax,  84 
Microcardia  in  phthisis,  113 
Midlobar  phthisis,  53,  102 
Miliary  tubercle,  20,  72 
Milliamperage,  I 
Miner's  phthisis,  64,  65 
Minor  phthisis,  48 
Mitral  stenosis  and  tubercle,  51,  64 

N 
Nasal  disease  and  tubercle,  98, 106 
Neurasthenia  and  tubercle,  18 
Nipple,  17,  56 
Nodal  chronic  phthisis,  39 

disseminated  fibroid  phthisis,  58 
Nodular  disseminated  fibroid  phthisis, 
58 

O 

Orthodiagraphy,  1 13 


Paralysis  of  recurrent  nerve,  51 
Paravertebral  triangle,  1 08 
Pectoriloquy  over  dorsal  spines,  29 
Perihilar  tubercle,  43,  5 1 

fibroid  tubercle,  55 

infiltration,  53 
Pertussis,  56,  75 

Phrenic  nerve,  faradisation  of,  16 
Phthisis  fibrosa,  58 

fibro-diffusa,  59 


Index 


119 


Pleural  effusion,  36 
encysted,  80 

interlobar  adhesions,  79 

space,  obliteration  of  (symphysis), 
82 

thickenings,  81,  82 
Pleurisy  and  tubercle,  78,  102 

diaphragmatic,  81 

dry,  81 
Pleuritis  tuberculosa  recidivans,  79 
Pneumonia  caseosa,  20,  71 

extensiva,  20 
Pneumoconiosis,  64,  65 
Pneumothorax  ballooning,  84 

diaphragm  in,  84 

displacement  in,  85 

effusion  in,  84 

operative,  84 

spontaneous,  45,  83 

succussion  in,  83 
Polymorphonucleosis,  26,  27 
Post-pleuritic  phthisis,  20 
Positions,  cardinal,  I 

anterior  or  dorso-ventral,  I 

left  antero-lateral  or  oblique,  6 

right  antero-lateral  or  oblique,  5 

posterior  or  ventro-dorsal,  5 

lateral,  7 
Pulmonary  artery,  6,  23 

congestion,  1 3 

fields,  2 

fibrosis,  58 
Pulse  in  phthisis,  30 


Rales,  medium,  94 
tuberculous,  95 
Recurrent  laryngeal  nerve,  23,  51 
Red  hepatisation,  70 
Reflex  bands  of  dulness,  25 
Reticulum,  pulmonary,  12 
Resolution  in  pneumonia,  39 
Rheumatism  and  tubercle,  27,  45 


Screens,  intensifying,  I 
Shadow,  median,  2 

paratracheal,  24 
Space,  retrocardiac,  67 
Spine,  scoliosis  of,  45 
Stereoscopy,  I 
Sulcus,  cardiophrenic,  3 


Sulcus,  costalis,  5 

costophrenic,  5 
Succussion-splash,  84 
Supraclavicular  apex,  1 06 
Syndrome,  pleural,  99 
Syphilis  and  phthisis,  62,  65 


Tachycardia,  113 
Telengiectases,  spinal,  95 
Temperature,  labile  in  phthisis,  30 
Thorax  aplati,  47 

rigidus,  16 

paralyticus,  47 
Thymus,  29 
Thyroid,  8,  27,  55 
Tracheal,  tugging,  113 
Tracheo-bronchial  glands,  23 
Triangles  of  chest,  9 

paravertebral,  108 
Tripier  on  miner's  phthisis,  65 
Tube,  X-ray,  quality  of,  i ,  93 
Tuberculosis  of  lungs,  arrested.  III 

and  pleurisy,  78,  102 

bronchiectasis  and,  66,  90 

cavities  of,  89,  100 

conjugal,  51 

fibroid,  58 

heart  in,  113 

haemoptysis  in,  88 

in  great  war,  90 

influence  of  age  in,  19 
of  dyscrasias  in,  19 

malaria  and,  112 

miliary,  20,  72 

mitral  stenosis  and,  5lf  64 

neurasthenia  and,  18 

onset  of,  18 

pneumonic,  68 

pneumothorax  in,  83 

primary  foci  of,  1 08,  1 09 

rales  in,  94,  95 

reinfection  in,  106 

resistance  in,  18 
Turban,  classification  of,  20 

U 

Unilateral  forms,  60 

W 

Wandering  pneumonia,  39 
Wounds  of  lung  and  tubercle,  100 


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